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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 e44 CLINICAL STATEMENTS AND GUIDELINES 7.3 Revascularization to Improve Symptoms Recommendations for Revascularization to Improve Symptoms Referenced studies that support the recommendations are summarized in Online Data Supplement 12. COR LOE Recommendations 1 A 1. In patients with refractory angina despite medical therapy and with significant coronary artery stenoses amenable to revascularization, revascularization is recommended to improve symptoms.1-6 3: Harm C-LD 2. In patients with angina but no anatomic or physiological criteria for revascularization, neither CABG nor PCI should be performed.7,8 Synopsis One of the main goals of coronary revascularization with either PCI or CABG surgery is to improve symptoms (Figure 6). In the treatment of patients with SIHD, medical therapy can often be an effective option. However, studies have shown that revascularization results in a greater improvement in angina or quality of life than does medical therapy alone.1-6 Additionally, some patients may be intolerant of or unwilling to take anti-anginal medications. For these reasons, revascularization is frequently used to provide symptom relief. Recommendation-Specific Supportive Text 1. Multiple RCTs have confirmed that revascularization improves anginal symptoms to a greater degree than optimal medical therapy.1-4,6,9,10 The results of the small ORBITA (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) trial,11 which randomized patients to PCI or a “sham” procedure, did not support an improvement in symptoms with PCI and raised questions about the placebo effect of PCI. However, the larger ISCHEMIA trial reported a clinically relevant improvement in symptoms at 3 years after PCI or CABG,1 long after a placebo effect should have dissipated. This difference was most pronounced among the patients with more frequent angina at baseline. In the FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial,4 both revascularization options were associated with significant improvement in angina and quality of life as compared with baseline. A greater improvement in health status was noted with CABG compared with PCI at intermediate-term follow-up, but this difference was no longer significant in longer-term follow-up. 2. Inappropriate revascularization of nonobstructive plaques with CABG can lead to progression of underlying CAD,7 and inappropriate use of PCI can cause periprocedural MIs8 and would not be expected to improve quality of life or anginal symptoms. 8 SITUATIONS IN WHICH PCI OR CABG WOULD BE PREFERRED 8.1 Patients With Complex Disease Recommendations for Patients With Complex Disease Referenced studies that support the recommendations are summarized in Online Data Supplement 13. COR LOE Recommendations 1 B-R 1. In patients who require revascularization for significant left main CAD with high-complexity CAD, it is recommended to choose CABG over PCI to improve survival.1,2 2a B-R 2. In patients who require revascularization for multivessel CAD with complex or diffuse CAD (eg, SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a survival advantage.2-5 Synopsis Revascularization with either CABG or PCI is indicated to treat symptoms or improve outcomes in specific subsets of patients. However, CABG and PCI are inherently different in the mechanisms by which they improve blood flow to the jeopardized myocardium. PCI will directly relieve a discrete obstruction and increase the arterial lumen in the stented area but will have no effect on preventing plaque progression or rupture in other diseased segments within the artery. In contrast, bypass of a coronary artery will improve blood flow to the jeopardized myocardium supplied by the diseased artery and will also protect the distal myocardial beds from future ischemic insult caused by proximal plaque progression or rupture. Although most studies comparing CABG and PCI have reported similar survival,1,3,5-17 certain subgroups of patients have been shown to derive a survival benefit from CABG compared with PCI.1,2,4,18 Additionally, compared with PCI, CABG may be more effective at reducing the risk of late spontaneous MI.11,19 Recommendation-Specific Supporting Text 1. The SYNTAX trial, which included 705 patients with left main stenoses and a range of complexity of disease, showed a significantly higher MACE and cardiac mortality rate at 5 years for the subgroup of patients with left main and high-complexity disease (defined as a SYNTAX score >33) who were treated with PCI.1 With the exception of the SYNTAX trial, the other RCTs comparing PCI with CABG in patients with left main disease excluded patients with complex disease.6,8,20 Individual factors that contribute to anatomic complexity (severe Downloaded from http://ahajournals.org by on October 7, 2026