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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e33 CLINICAL STATEMENTS AND GUIDELINES between FFR values and IVUS minimal lumen area cutoffs have been demonstrated in left main disease.4,5 Compared with the left main artery, smaller cutoffs have been suggested for IVUS of the LAD artery.7 Developed more recently, optical coherence tomography (OCT) has been shown to correlate well with IVUS measurements.8 However, because OCT requires blood clearance, its effectiveness for imaging ostial left main disease is limited. 5 REVASCULARIZATION IN STEMI 5.1 Revascularization of the Infarct Artery in Patients With STEMI Recommendations for Revascularization of the Infarct Artery in Patients With STEMI Referenced studies that support the recommendations are summarized in Online Data Supplement 7. COR LOE Recommendations 1 A 1. In patients with STEMI and ischemic symptoms for <12 hours, PCI should be performed to improve survival.1-5 1 B-R 2. In patients with STEMI and cardiogenic shock or hemodynamic instability, PCI or CABG (when PCI is not feasible) is indicated to improve survival, irrespective of the time delay from MI onset.6,7 1 B-NR 3. In patients with STEMI who have mechanical complications (eg, ventricular septal rupture, mitral valve insufficiency because of papillary muscle infarction or rupture, or free wall rupture), CABG is recommended at the time of surgery, with the goal of improving survival.8,9 1 C- LD 4. In patients with STEMI and evidence of failed reperfusion after fibrinolytic therapy, rescue PCI of the infarct artery should be performed to improve clinical outcomes.10-13 2a B-R 5. In patients with STEMI who are treated with fibrinolytic therapy, angiography within 3 to 24 hours with the intent to perform PCI is reasonable to improve clinical outcomes.14-20 2a B-NR 6. In patients with STEMI who are stable and presenting 12 to 24 hours after symptom onset, PCI is reasonable to improve clinical outcomes.21,22 2a B-NR 7. In patients with STEMI in whom PCI is not feasible or successful, with a large area of myocardium at risk, emergency or urgent CABG can be effective as a reperfusion modality to improve clinical outcomes.23,24 2a C-EO 8. In patients with STEMI complicated by ongoing ischemia, acute severe heart failure, or lifethreatening arrhythmia, PCI can be beneficial to improve clinical outcomes, irrespective of time delay from MI onset. 3: No Benefit B-R 9. In asymptomatic stable patients with STEMI who have a totally occluded infarct artery >24 hours after symptom onset and are without evidence of severe ischemia, PCI should not be performed.25,26 3: Harm C-EO 10. In patients with STEMI, emergency CABG should not be performed after failed primary PCI: • In the absence of ischemia or a large area of myocardium at risk, or • If surgical revascularization is not feasible because of a no-reflow state or poor distal targets. Synopsis Immediate reperfusion therapy for patients with STEMI improves mortality rate, and primary PCI has been shown to be superior to fibrinolytic therapy1 (Figure 3).6,23,27-29 Fibrinolytic therapy is recommended only in cases in which primary PCI is not immediately available and the delay from hospital presentation to PCI is anticipated to be >120 minutes.30 Because approximately 35% of patients treated with fibrinolysis do not achieve reperfusion,31 and an additional 10% have ineffective reperfusion (TIMI [Thrombolysis In Myocardial Infarction] flow grade <3),1 early transfer of patients to centers capable of performing PCI will facilitate early catheterization and/or PCI.15-17,19 CABG has a limited role in the acute phase of STEMI, and its use in this setting continues to decrease.23 Older case series have highlighted a potential excess mortality risk when CABG is performed early after STEMI.32 However, contemporary modifications to the standard operative approach, improved anesthesia and monitoring, improved technical methods, and adjunctive temporary mechanical circulatory support devices may lead to improved rates of survival after CABG (Figure 3). Recommendation-Specific Supportive Text 1. Multiple RCTs and meta-analyses have shown that primary PCI reduces death, MI, stroke, and major bleeding as compared with fibrinolysis, especially when treatment delays are minimized.1-5 This benefit is seen even among patients transferred from non-PCI hospitals if transfer times are reasonable and total ischemic time after presentation is <120 minutes.4,30 2. In patients with STEMI complicated by cardiogenic shock, an early revascularization strategy is associated with a significant survival benefit.6 In the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial, although the primary endpoint of 30-day survival for patients with STEMI and cardiogenic shock was not improved with early revascularization, compared with initial medical stabilization,6 the secondary outcome of mortality rate at 6 months was significantly lower in the group of patients randomized to early revascularization and treated with either PCI or CABG. Recommendations for Revascularization of the Infarct Artery in Patients With STEMI (Continued ) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026