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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 e49 CLINICAL STATEMENTS AND GUIDELINES

2.	 On the basis of multiple randomized trials, prompt coronary angiography and revascularization have been recommended for patients presenting with STEMI.34 However, patients with severe CKD were often excluded from these studies because of their higher risk of adverse ischemic and bleeding events, as well as their higher risk of contrastinduced AKI. Nonetheless, the mortality benefit of revascularization in patients with STEMI and CKD outweighs the risk of adverse outcomes when adequate measures to reduce the risk of AKI are taken before, during, and after the procedure. 3.	 Several observational studies have reported worse in-hospital outcomes and long-term mortality rate for patients with NSTE-ACS and CKD than for those without CKD.35-37 Despite this, an early invasive strategy in high-risk patients with NSTE- ACS was shown to be associated with significant risk reduction versus a noninvasive approach.9 Although the use of PCI for NSTE-ACS has been found to decrease with increasing CKD severity, revascularization in these patients is associated with a lower in-hospital mortality rate than that seen with medical management.5 4.	 Although a routine invasive approach has been shown to improve outcomes in patients presenting with NSTE-ACS, this risk reduction was evident mostly in the high-risk subgroups.9 The risk–benefit ratio of revascularization in patients with low-risk NSTE-ACS remains uncertain because of limited evidence. Therefore, in low-risk patients with NSTE-ACS with CKD, astute clinical judgment weighing the trade-off between risks and benefits is required to determine the optimal approach in this patient subgroup. 5.	 ISCHEMIA-CKD was the first randomized trial to test the benefit of adding cardiac catheterization and, if feasible, revascularization to GDMT in stable patients with moderate CKD and at least moderate ischemia.6 With patients randomized to either an invasive or conservative strategy, an initial invasive strategy did not demonstrate a reduced risk of clinical outcomes or improved quality-of-life measures compared with an initially conservative strategy.

9.4 Revascularization in Patients Before

Noncardiac Surgery Recommendation for Revascularization in Patients Before Noncardiac Surgery Referenced studies that support the recommendation are summarized in Online Data Supplement 20.

COR LOE Recommendation

3: No benefit B-R 1.	 In patients with non–left main or noncomplex CAD who are undergoing noncardiac surgery, routine coronary revascularization is not recommended solely to reduce perioperative cardiovascular events.1

Synopsis Patients with significant CAD who are undergoing highrisk surgery, such as solid organ transplantation2 or vascular surgery,3 have an increased incidence of perioperative cardiovascular events. Routine prophylactic revascularization does not reduce the risk of death or cardiovascular events.1 Clinical studies have excluded or randomized few patients with high-risk coronary anatomy such as unprotected left main and multivessel CAD. Additionally, these studies did not include patients referred for solid organ transplantation. In such patients, a Heart Team approach would be used to determine the risks and benefits of revascularization. In symptomatic patients or patients with other clinical indications for revascularization, coronary revascularization should be considered in accordance with the recommendations otherwise provided for such situations, but revascularization should not be done for the sole purpose of reducing perioperative complications.

Recommendation-Specific Supportive Text

1.	 One clinical trial has shown a lack of benefit for routine revascularization in patients before vascular surgery.1 The CARP (Coronary Artery Revascularization Prophylaxis) study randomized 510 asymptomatic patients with ≥1 significant coronary lesion to revascularization with PCI or CABG or to medical therapy and found no difference in 30-day and 1-year rates of death or MI. Most patients in this study had only single- or 2-vessel CAD, and patients with left main CAD, left ventricular ejection fraction <20%, or severe aortic stenosis were excluded.1 Nonrandomized patients with unprotected left main CAD who were excluded from the CARP study did derive benefit from revascularization.3

Table 8.  Best Practices in the Catheterization Laboratory for Patients With CKD Undergoing Angiography Assess the risk of contrast-induced AKI before the procedure1-3 Administer adequate preprocedural hydration19,20 Record the volume of contrast media administered, and minimize contrast use18,22,23 Pretreat with high-intensity statins21,24,25 Use radial artery if feasible31-33 Do not administer N-acetyl-L-cysteine to prevent contrast-induced AKI38-40 Do not give prophylactic renal replacement therapy41,42 Delay CABG in stable patients after angiography beyond 24 hours when clinically feasible43-45 AKI indicates acute kidney injury; CABG, coronary artery bypass graft; and CKD, chronic kidney disease.

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