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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 e48 CLINICAL STATEMENTS AND GUIDELINES Synopsis Although the terms “elderly” or “older” have been used to describe various patient-age subgroups in the literature, most clinical trials have defined older patients as those ≥75 years of age.3 Older patients form a vulnerable subset of patients undergoing coronary revascularization because of their more complex presentations and higher prevalence of comorbidities.4,5 In addition, they have an increased risk of bleeding complications and stroke after PCI.3,6-8 However, the optimal treatment for older patients with an indication for revascularization remains poorly defined because most studies have excluded older patients and included only low-risk populations.9 Recommendation-Specific Supportive Text 1. Older patients constitute a growing, high-risk population with increased rates of adverse events.10-12 These patients pose additional challenges because of adverse interactions caused by polypharmacy and age-related changes in cardiovascular function and coronary anatomy.5,13-15 Although older patients benefit from revascularization to the same, if not greater, extent as younger patients,16 the optimal strategy should be chosen according to patientcentered goals of care.17 Subgroup analyses from recent randomized trials have demonstrated that relative outcomes after PCI and CABG are comparable in older patients, with CABG being better at achieving complete revascularization, whereas PCI is preferred for frail patients at higher risk of periprocedural events.18-21 Careful consideration of risks and benefits using a Heart Team, and in accordance with the patient’s preferences, while accounting for frailty and cognitive status, is vital in decisions about the appropriate revascularization plan for older patients. 9.3 Revascularization in Patients With Chronic Kidney Disease (CKD) Recommendations for Revascularization in Patients With CKD Referenced studies that support the recommendations are summarized in Online Data Supplement 19. COR LOE Recommendations 1 C-LD 1. In patients with CKD undergoing contrast media injection for coronary angiography, measures should be taken to minimize the risk of contrast-induced acute kidney injury (AKI).1-3 1 C-EO 2. In patients with STEMI and CKD, coronary angiography and revascularization are recommended, with adequate measures to reduce the risk of AKI. 2a B-NR 3. In high-risk patients with NSTE-ACS and CKD, it is reasonable to perform coronary angiography and revascularization, with adequate measures to reduce the risk of AKI.4,5 2a C-EO 4. In low-risk patients with NSTE-ACS and CKD, it is reasonable to weigh the risk of coronary angiography and revascularization against the potential benefit. 3: No benefit B-R 5. In asymptomatic patients with stable CAD and CKD, routine angiography and revascularization are not recommended if there is no compelling indication.6 Synopsis Patients with CKD constitute a growing subset of the population7,8 and have been found to have worse outcomes after AMI or PCI.9,10 Risk of cardiovascular death has been shown to be inversely proportional to estimated glomerular filtration rate, with impaired renal function being an independent predictor of cardiovascular risk.11,12 Although about 30% to 40% of all patients undergoing PCI have concomitant CKD,13,14 data on optimal treatment strategies in this population remain scarce because most RCTs have traditionally excluded patients with severe CKD. Patients with CKD who present with ACS are less likely to receive GDMT or invasive angiography than are patients with normal renal function, and the likelihood of undergoing cardiovascular interventions decreases with increasing severity of CKD.9,15-17 Before coronary angiography is performed, the risks of AKI and the benefits of obtaining diagnostic information should be carefully considered. Preexisting CKD is the strongest independent risk factor for the development of AKI, with a higher stage of CKD associated with incrementally higher risk.6,7 Recommendation-Specific Supportive Text 1. Adequate hydration18-20 and minimization of the volume of contrast media21-23 remain the principal strategies for contrast-induced nephropathy prevention (Table 8). High-dose statins before diagnostic catheterization have been demonstrated to reduce the occurrence of contrastinduced AKI21,24,25 because of their pleotropic effects that decrease systemic inflammation, possibly by decreasing the synthesis of endothelin-1 and inhibiting tissue-factor expression by macrophages.26-29 Atheroembolism may have a role in AKI after PCI,30 and a transfemoral approach may increase this risk because of the proximity to renal arteries.31 Consistent with this, the use of radial access has been shown to significantly reduce the risk of AKI compared with femoral access.31-33 All other measures believed to reduce the risk of contrast-induced AKI have not demonstrated significant clinical benefit.12,31 Recommendations for Revascularization in Patients With CKD (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026