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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

Synopsis Studies have shown that CABG confers a survival benefit over medical therapy in multiple subsets of patients, including those with left main CAD (Figure 6),9-12 triple-vessel CAD,13 and ischemic cardiomyopathy.1,3-7,31-33 Many of these studies were conducted before the widespread use of antiplatelet and statin therapies and before the broad recognition of benefit from beta-blockers and ACE inhibitors/ARBs. There are no RCTs that have demonstrated a survival advantage of PCI over medical therapy in patients with SIHD.14,17,34-38 There may be an advantage of PCI over medical therapy in patients who have a clinical indica- tion for CABG but are deemed prohibitive surgical risk. For this reason, the Heart Team must weigh the risks and benefits of PCI as compared to medical therapy in such patients. The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial randomized patients with SIHD and moderate-to-severe ischemia on stress testing to an initial invasive strategy versus an initial conservative strategy. Patients with left main disease or an ejection fraction <35% were excluded from enrollment. As compared with a strategy of medical therapy alone, an invasive strategy including revascularization with PCI or CABG was not associated with improved outcomes.14

Figure 6. Revascularization in Patients With SIHD. Colors correspond to Table 2. CABG indicates coronary artery bypass graft; CAD, coronary artery disease; EF, ejection fraction; GDMT, guideline-directed medical therapy; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart disease. This algorithm summarizes the recommendations in this guideline for the care of patients with stable CAD. 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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