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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 e47 CLINICAL STATEMENTS AND GUIDELINES 8.4 DAPT Adherence Recommendation for DAPT Adherence Referenced studies that support the recommendation are summarized in Online Data Supplement 16. COR LOE Recommendation 2a B-NR 1. In patients with multivessel CAD amenable to treatment with either PCI or CABG who are unable to access, tolerate, or adhere to DAPT for the appropriate duration of treatment, CABG is reasonable in preference to PCI.1-10 Synopsis In patients undergoing coronary revascularization, careful consideration should be given to factors that may affect adherence to medications, including patient preferences and comorbidities, socioeconomic status, and lifestyle factors. Premature cessation of DAPT after PCI is associated with stent thrombosis and poor outcomes, including death.1-10 Therefore, PCI is not favored as the mode of revascularization among patients manifesting risk factors for poor adherence. Recommendation-Specific Supporting Tex 1. Stent thrombosis after PCI is associated with large-territory MI and poor outcomes, with death rates as high as 50% for early thrombosis cases.1,5,9 Risk factors for stent thrombosis are many and include patient-, lesion-, and treatment-specific factors.2 Early DAPT interruption— for bleeding, procedures, or nonadherence—is a reversible risk factor that is strongly associated with stent thrombosis, particularly early after PCI, with the relative increase in stent thrombosis rates between 2-fold and >20-fold.2,4,8,10 Given the morbidity and mortality associated with stent thrombosis and the strong association of nonuse of DAPT with stent thrombosis, CABG is a safe revascularization option in patients who are not likely to be adherent to DAPT. 9 SPECIAL POPULATIONS AND SITUATIONS 9.1. Revascularization in Pregnant Patients Recommendations for Revascularization in Pregnant Patients Referenced studies that support the recommendations are summarized in Online Data Supplement 17. COR LOE Recommendations 2a C-LD 1. In pregnant patients with STEMI not caused by spontaneous coronary artery dissection (SCAD), it is reasonable to perform primary PCI as the preferred revascularization strategy.1,2 2a C-LD 2. In pregnant patients with NSTE-ACS, an invasive strategy is reasonable if medical therapy is ineffective for the management of lifethreatening complications.1,2 Synopsis In pregnant patients, an expanded, multidisciplinary Heart Team approach is often used to determine the appropriate coronary revascularization treatment, with consideration of patient preferences, comorbidities, and clinical status. Decisions in pregnant patients are often difficult and must include consideration of the risk to the unborn fetus, as well as the risks and benefits to the mother. Pregnant women are generally excluded from clinical trials, and therefore there is limited evidence regarding the safety of antiplatelet agents during pregnancy, especially during the third trimester. Low-dose aspirin is generally felt to be safe throughout pregnancy. If clopidogrel is needed, it should be used for the shortest duration possible3,4 with close monitoring. In a recent systematic review of 39 publications with 42 live births, the outcomes for both mothers and neonates when exposed to clopidogrel at varying durations throughout gestation, did not suggest higher than acceptable risk, with a congenital anomaly rate comparable to background risk. The evidence regarding the use of other antiplatelet agents remains limited.4 Recommendation-Specific Supportive Text 1. The coronary revascularization treatment in the pregnant patient with STEMI is typically via PCI,5 and CABG is usually performed when medical therapy or PCI fails and the mother’s life is threatened.1,2 In a large, retrospective review of pregnant patients with AMI, STEMI was noted in 42% of these patients. Approximately 25% to 40% of pregnant patients with AMI were referred for invasive evaluation, and roughly 25% of pregnant patients received coronary revascularization (with most patients receiving PCI). Compared with a conservative approach, an invasive approach for the treatment of the AMI was associated with a significantly lower adjusted inhospital mortality rate. 2. In a large database of pregnant patients with AMI,2 a larger proportion of patients with NSTE-ACS were conservatively treated. If medical therapy is ineffective for the management of these patients because of ongoing ischemia, hemodynamic comprise, or electrical instability, an invasive approach was noted to be reasonable.2,5,6 9.2 Revascularization in Older Patients Recommendation for Revascularization in Older Patients Referenced studies that support the recommendation are summarized in Online Data Supplement 18. COR LOE Recommendation 1 B-NR 1. In older adults, as in all patients, the treatment strategy for CAD should be based on an individual patient’s preferences, cognitive function, and life expectancy.1,2 Downloaded from http://ahajournals.org by on October 7, 2026