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

January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e38

CLINICAL STATEMENTS AND GUIDELINES 6 REVASCULARIZATION IN NSTE-ACS

6.1 Coronary Angiography and

Revascularization in Patients With NSTE-ACS Recommendations for Coronary Angiography and Revascularization in Patients With NSTE-ACS Referenced studies that support the recommendations are summarized in Online Data Supplement 9.

COR LOE Recommendations

1 A 1.	 In patients with NSTE-ACS who are at elevated risk of recurrent ischemic events and are appropriate candidates for revascularization, an invasive strategy with the intent to proceed with revascularization is indicated to reduce cardiovascular events.1-4

1 B-R 2.	 In patients with NSTE-ACS and cardiogenic shock who are appropriate candidates for revascularization, emergency revascularization is recommended to reduce risk of death.5-9

1 C-LD 3.	 In appropriate patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability, an immediate invasive strategy with intent to perform revascularization is indicated to improve outcomes.10

2a B-R 4.	 In patients with NSTE-ACS who are initially stabilized and are at high risk of clinical events, it is reasonable to choose an early invasive strategy (within 24 hours) over a delayed invasive strategy to improve outcomes.11-16

2a B-R 5.	 In patients with NSTE-ACS who are initially stabilized and are at intermediate or low risk of clinical events, an invasive strategy with intent to perform revascularization is reasonable before hospital discharge to improve outcomes.11-16

2a B-NR 6.	 In patients with NSTE-ACS who have failed PCI and have ongoing ischemia, hemodynamic compromise, or threatened occlusion of an artery with substantial myocardium at risk, who are appropriate candidates for CABG, emergency CABG is reasonable.5-7,17

3: Harm B-R 7.	 In patients with NSTE-ACS who present in cardiogenic shock, routine multivessel PCI of non-culprit lesions in the same setting should not be performed.18,19

Synopsis A routine invasive approach for patients with NSTE- ACS is associated with improved outcomes.1-4,20,21 Risk stratification with a validated score (ie, GRACE or TIMI) has been recommended to guide the timing of coronary angiography.22,23 The GRACE score has been used in most clinical trials to identify patients who were at high risk of death or MI. It enables a direct estimation of the mortality risk during hospitalization and at longer term followup.24 Traditionally, a GRACE score of >140 had been used to denote a patient at higher risk of in-hospital clinical events. Other factors associated with higher risk include older age (≥75 years), elevated TIMI risk score (https://timi.org/calculators/timi-riskscore-calculator-for-ua-nstemi/),25 and elevated cardiac markers.11,26 Factors indicating a need for an urgent revascularization (Table 7) with either PCI or CABG include threatening anatomy, ongoing ischemia, or hemodynamic compromise. In such patients and in those with complex CAD, treatment should be individualized and involve a Heart Team discussion.

Recommendation-Specific Supportive Text

1.	 In patients with NSTE-ACS, an initial invasive approach is associated with a lower rate of the combined endpoint of death, MI, or refractory angina at 4 to 6 months’ follow-up1-4 (Figure 5). Pooled trial data have demonstrated lower rates of recurrent infarction and recurrent ischemia with an invasive strategy.4 The benefits of an invasive approach are most pronounced among patients with elevated biomarkers or other higher-risk findings.1 The invasive approach also provides important prognostic information, such as extent and severity of CAD, hemodynamics, and left ventricular function, allowing for precise determination of risk, antithrombotic treatment guidance, and suitability for revascularization with PCI or CABG. Roughly 20% to 25% of patients enrolled in the early trials examining the benefits of a routine invasive approach underwent CABG. In patients with multivessel disease, the mode of revascularization should be based on the acuity of the patient’s condition, the angiographic characteristics of the culprit lesion, and the complexity of the

Table 7.  Patient Clinical Status Definitions to Guide Revascularization13-15 Elective The patient’s cardiac function has been stable in the days or weeks before intervention (whether surgical or procedural). The intervention could be deferred without increased risk of compromise to cardiac outcome. Urgent Intervention is required during the same hospitalization to minimize chance of further clinical deterioration. Examples include, but are not limited to, worsening sudden chest pain, heart failure, acute myocardial infarction, anatomy, intra-aortic balloon pump, unstable angina, with intravenous nitroglycerin, or rest angina. Emergency Patients requiring emergency intervention will have ongoing, refractory (difficult, complicated, and/or unmanageable), unrelenting cardiac compromise, with or without hemodynamic instability, and not responsive to any form of therapy except cardiac intervention. An emergency intervention is one in which there should be no delay in providing operative intervention. Emergency/ salvage Patients requiring emergency/salvage intervention are those who require cardiopulmonary resuscitation en route to the operating room, or procedure room, before induction of anesthesia or who require extracorporeal membrane oxygenation to maintain life.

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