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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 e40 CLINICAL STATEMENTS AND GUIDELINES support the use of an early invasive strategy for high-risk patients.11,12,16 The TIMACS (Timing of Intervention in Acute Coronary Syndromes) trial, in which patients were enrolled within 24 hours of symptoms and randomized to angiography at ≤ 24 hours versus ≥ 36 hours from time of randomization, and the VERDICT (Very Early vs Deferred Invasive Evaluation Using Computerized Tomography) trial, in which patients were randomized to angiography at <12 hours versus 48 to 72 hours from time of diagnosis, both evaluated the value of early invasive management of symptoms for patients with NSTE-ACS and demonstrated a lower rate of cardiovascular events in follow-up in the high-risk subgroup of patients randomized to early angiography. 5. In intermediate- or low-risk patients, timing is not critical, and a delayed invasive strategy within 48 to 72 hours has been demonstrated to be acceptable11-16,28 Randomized trial data have not demonstrated differences in rates of death and MI between an early invasive strategy (coronary angiography <24 hours after admission) and a delayed invasive approach (48–72 hours) in a nonselected population of patients with NSTEMI.11-16,29,30 However, low-risk patients benefit from a routine invasive strategy before hospital discharge, with a significant reduction in the risk of cardiovascular death or MI, compared with a selective invasive strategy.21 6. Although there are no randomized trials specifically evaluating emergency CABG versus medical therapy or delayed revascularization in patients with NSTE-ACS and failed PCI who have ongoing ischemia or hemodynamic compromise, multiple retrospective reviews have noted a reduced mortality rate in patients with an emergency approach.6,9,17 The appropriate safe timing of CABG is carefully determined with a Heart Team approach in patients with NSTE-ACS who are on dual antiplatelet therapy (DAPT). 7. In the CULPRIT-SHOCK trial, almost 40% of enrolled patients had an NSTEMI. As mentioned in section 5.2, patients were included in the trial if they had 2 or more vessels with >70% diameter stenosis that were ≥2 mm in diameter. Those with chronic total occlusions were eligible for inclusion in the study. Patients in the CULPRIT-SHOCK trial who were randomized to culprit-only PCI with the option of staged revascularization of non-culprit lesions had a lower rate of the composite endpoint of death and dialysis at 30 days and 1 year. Culprit-vessel PCI was associated with a significant all-cause mortality rate reduction at 30 days but not at 1 year.18,19 As was noted in patients with STEMI, the results of the CULPRIT-SHOCK trial showed no benefit to immediate multivessel PCI in NSTEMI. 7 REVASCULARIZATION IN SIHD 7.1 Revascularization to Improve Survival in SIHD Compared With Medical Therapy Recommendations for Revascularization to Improve Survival in SIHD Compared With Medical Therapy Referenced studies that support the recommendations are summarized in Online Data Supplement 10. COR LOE Recommendations Left ventricular dysfunction and multivessel CAD 1 B-R 1. In patients with SIHD and multivessel CAD appropriate for CABG with severe left ventricular systolic dysfunction (left ventricular ejection fraction <35%), CABG is recommended to improve survival.1,2 2a B-NR 2. In selected patients with SIHD and multivessel CAD appropriate for CABG and mild-to-moderate left ventricular systolic dysfunction (ejection fraction 35%–50%), CABG (to include a left internal mammary artery [LIMA] graft to the LAD) is reasonable to improve survival.3-8 Left main CAD 1 B-R 3. In patients with SIHD and significant left main stenosis, CABG is recommended to improve survival.9-12 2a B-NR 4. In selected patients with SIHD and significant left main stenosis for whom PCI can provide equivalent revascularization to that possible with CABG, PCI is reasonable to improve survival.9 Multivessel CAD 2b B-R 5. In patients with SIHD, normal ejection fraction, significant stenosis in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for CABG, CABG may be reasonable to improve survival.10,13-15 2b B-R 6. In patients with SIHD, normal ejection fraction, significant stenosis in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for PCI, the usefulness of PCI to improve survival is uncertain.14-24 Stenosis in the proximal LAD artery 2b B-R 7. In patients with SIHD, normal left ventricular ejection fraction, and significant stenosis in the proximal LAD, the usefulness of coronary revascularization to improve survival is uncertain.10,14,17,24-27 Single- or double-vessel disease not involving the proximal LAD 3: No Benefit B-R 8. In patients with SIHD, normal left ventricular ejection fraction, and 1- or 2-vessel CAD not involving the proximal LAD, coronary revascularization is not recommended to improve survival.10,14,16,26,28,29 3: Harm B-NR 9. In patients with SIHD who have ≥1 coronary arteries that are not anatomically or functionally significant (<70% diameter of non–left main coronary artery stenosis, FFR >0.80), coronary revascularization should not be performed with the primary or sole intent to improve survival.26,30 Downloaded from http://ahajournals.org by on October 7, 2026