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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e43 CLINICAL STATEMENTS AND GUIDELINES The preponderance of newer evidence against a survival advantage of PCI comes from the ISCHEMIA trial itself,14 which is consistent with the results of multiple earlier RCTs17-23 and multiple contemporary meta-analyses15,60-62 incorporating the ISCHEMIA trial results,14 all of which have not shown a survival advantage for PCI over medical therapy for patients with multivessel CAD. Stenosis in the Proximal LAD Artery 7. An earlier meta-analysis10 and several earlier registry studies26,29 suggested a survival advantage of CABG over medical therapy in patients with disease in the proximal LAD. Additionally, a network meta-analysis found a survival advantage for PCI.37 However, a dedicated RCT found no survival advantage for either CABG or PCI over medical therapy in this setting,64,65 and the ISCHEMIA trial14 showed no difference in event rates with either CABG or PCI over medical therapy when patients had multivessel CAD involving the proximal LAD. In the ISCHEMIA trial, close to half of enrolled patients had >50% stenosis of the proximal LAD; in this study, there was no heterogeneity of treatment effect on outcomes with the presence of LAD disease. Single- or Double-Vessel Disease Not Involving the Proximal LAD 8. A clinical principle from several studies is that the more myocardium is at risk, the greater is the survival advantage of revascularization over medical therapy, and in patients with little myocardium at risk (1- or 2-vessel CAD without LAD involvement), there is likely no survival benefit of revascularization in patients with SIHD.10,17,26,29,37 9. In patients without clinical or physiological evidence of significant disease, bypass surgery of nonobstructive disease has been reported to stimulate progression of CAD,66 and PCI may precipitate periprocedural MIs23 and is not associated with improved outcomes.30,67-69 7.2 Revascularization to Reduce Cardiovascular Events in SIHD Compared With Medical Therapy Recommendation for Revascularization to Reduce Cardiovascular Events in SIHD Compared With Medical Therapy Referenced studies that support the recommendation are summarized in Online Data Supplement 11. COR LOE Recommendation 2a B-R 1. In patients with SIHD and multivessel CAD appropriate for either CABG or PCI, revascularization is reasonable to lower the risk of cardiovascular events such as spontaneous MI, unplanned urgent revascularizations, or cardiac death.1-8 Synopsis Clinical practice guidelines have traditionally included recommendations for revascularization in patients with SIHD based on the ability of CABG or PCI to improve overall survival (Section 7.1.) or to reduce ischemic symptoms (Section 7.3.), as compared with medical therapy alone. However, there are other clinical events that can affect a patient’s overall prognosis, and that remain important considerations for patients. Several studies suggest that revascularization with CABG or PCI lowers the risk of adverse events such as cardiac death, MI, or urgent revascularization compared with medical therapy alone.2,5,6,9,10 Recommendation-Specific Supporting Text 1. In MASS (Medicine, Angioplasty or Surgery Study) II, the 10-year rates of cardiac death were lower after CABG or PCI than after medical therapy alone.2 Lower rates of cardiac death were seen after revascularization than with medical therapy alone in a meta-analysis of 25 studies enrolling 19 806 patients.3 However, a statistically nonsignificant reduction was seen in a concurrent meta-analysis of 12 103 patients enrolled in 7 RCTs.8 Several other studies found no difference in cardiac death after revascularization than with medical therapy alone.10,11 Cardiac death may be related to the occurrence of MI after revascularization.12 The relative prognostic importance of procedural MIs versus that of late spontaneous MIs remains uncertain.13 In the ISCHEMIA trial,1 the incidence of procedural type 4a or type 5 MIs was increased with revascularization, but the incidence of late MI (spontaneous MI [type 1], demand-induced MI [type 2], or MIs associated with stent thrombosis [type 4b] or with restenosis [type 4c]) was reduced. A preplanned analysis of the MI patterns in the ISCHEMIA trial4 found that all-cause death was increased with spontaneous MIs but not with procedural MIs. A large network meta-analysis found that spontaneous MI was reduced by revascularization compared with medical therapy alone.3 However, a concurrent analysis found an increased rate of procedural MI, a reduced rate of nonprocedural MI, and no difference in overall MI.11 On the contrary, another meta-analysis of stable patients, did not show a reduction in MI with revascularization,10 and 1 other study reported reduction in MI with CABG but not with PCI.9 Revascularization with CABG or PCI may reduce the need for subsequent urgent revascularization or hospitalization for acute coronary events.5-8 Downloaded from http://ahajournals.org by on October 7, 2026