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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

CLINICAL STATEMENTS AND GUIDELINES

January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038

3.	 The mortality rate associated with emergency CABG and surgical management of a mechanical complication of STEMI remains high.33 However, there are currently few medical or percutaneous treatment methods to effectively treat ventricular rupture, papillary muscle rupture leading to severe mitral regurgitation, or ischemic ventricular septal defect. CABG and these associated procedures may be necessary to treat the mechanical complications of STEMI or cardiogenic shock in the emergency setting.34-38 Placement of a mechanical support device may be useful in temporizing a patient with a mechanical complication of STEMI, and urgent or emergency surgery remains the best treatment.39,40 No RCT has examined the benefit of adding CABG at the time of emergent cardiac surgery for treatment of a mechanical complication of STEMI versus emergent surgery for the treatment of a mechanical complication alone. In addition, no RCT has examined the benefit of emergent cardiac surgery for the treatment of a mechanical complication of STEMI versus initial medical stabilization and delayed surgery. 4.	 Rescue PCI performed in patients with evidence of failed reperfusion after fibrinolytic therapy has been associated with a reduction in cardiovascular events,10-13 when compared with conservative care or repeat fibrinolysis. In these studies, patients randomized to rescue PCI had higher rates of bleeding and cerebrovascular accident.10-12 All these studies were performed in the era of femoral artery access, with limited options for antiplatelet and anticoagulant therapy. Previous concerns about increased bleeding or increased stroke risk in patients undergoing rescue PCI could be mitigated by using halfdose tenecteplase in patients >75 years of age,31 by substituting radial access in place of femoral access,41 or by eliminating the routine use of platelet glycoprotein IIb/IIIa inhibitors. With these techniques, the reduced complications associated with PCI would provide a more favorable balance of risk

Figure 3. Indications for Revascularization in STEMI (Patients Without Fibrinolytics). Colors correspond to Table 2. CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; and STEMI, ST-segment–elevation myocardial infarction. This algorithm summarizes the recommendations in this guideline for revascularization of the infarct artery in STEMI. It is not meant to encompass every patient scenario or situation, and clinicians are encouraged to use a Heart Team approach when care decisions are unclear and to see the accompanying supportive text for each recommendation. Additionally, in situations that lack sufficient data to make formal recommendations for care, please see Section 17, “Unanswered Questions and Future Directions.”

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