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

CLINICAL STATEMENTS AND GUIDELINES

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

patient’s anatomy and, when appropriate, should include a Heart Team discussion. 2.	 In the SHOCK trial, patients were randomized to medical therapy or emergency revascularization. Among the patients randomized to revascularization, twothirds of patients were referred for PCI and one-third for CABG, and the decision to proceed with PCI or CABG was made by the treating physician.9 Median time from randomization to revascularization was 0.9 hours for PCI and 2.7 hours for CABG. The SHOCK trial supported a strategy of emergency angiography with immediate revascularization in patients with AMI complicated by cardiogenic shock. At 6 months, the mortality rate was significantly lower in patients randomized to revascularization than in those randomized to medical therapy.9 In the SHOCK trial, there was no difference in mortality rate with PCI or CABG for those patients randomized to early revascularization, with a similar survival regardless of the mode of revascularization at 30 days and 1 year. Additionally, observational studies5-7,17 of patients with cardiogenic shock referred for CABG have reported acceptable outcomes with emergency revascularization. Patients with shock may benefit from mechanical circulatory support devices before revascularization, especially if CABG is planned.27

3.	 Patients with NSTE-ACS who are clinically unstable because of refractory angina, intractable arrhythmias, or hemodynamic instability have been consistently excluded from clinical trials evaluating the optimal timing of coronary angiography.11,28 Although evidence from clinical trial data is lacking, intuitively, immediate angiography (within 2 hours) with plans for appropriate revascularization would be expected to improve outcomes if revascularization stabilizes the clinical condition. 4.	 An early invasive strategy performed within 24 hours in high-risk (GRACE score >140) patients is associated with a lower incidence of recurrent ischemia or need for urgent revascularization and a shorter hospital stay.11,12,14-16 Although clinical trials have not demonstrated a clear advantage with an early invasive strategy (within 24 hours) as opposed to a delayed invasive strategy in the overall population of patients with NSTE-ACS,12,16 prespecified subgroup analyses of these trials

Figure 5. Recommendations for the Timing of Invasive Strategy in Patients With NSTE-ACS. Colors correspond to Table 2. GRACE indicates Global Registry of Acute Coronary Events; and NSTE-ACS, non–ST-segment–elevation acute coronary syndrome. *https://www.mdcalc.com/grace-acs-risk-mortality-calculator.31 This algorithm summarizes the recommendations in this guideline for coronary artery angiography with the intent to perform revascularization in NSTE-ACS. 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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