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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 e50 CLINICAL STATEMENTS AND GUIDELINES 9.5 Revascularization in Patients to Reduce Ventricular Arrhythmias Recommendations for Revascularization in Patients to Reduce Ventricular Arrhythmias Referenced studies that support the recommendations are summarized in Online Data Supplement 21. COR LOE Recommendations 1 B-NR 1. In patients with ventricular fibrillation, polymorphic ventricular tachycardia (VT), or cardiac arrest, revascularization of significant CAD is recommended to improve survival.1-4 3: No Benefit C-LD 2. In patients with CAD and suspected scarmediated sustained monomorphic VT, revascularization is not recommended for the sole purpose of preventing recurrent VT.5-9 Synopsis In patients with ventricular arrhythmias, the evaluation for potential ischemic CAD will guide appropriate treatment, including coronary revascularization.10,11 The “2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death” describes situations in which CABG or PCI may benefit patients with ischemic CAD.12 Observational studies have shown that revascularization in patients with life-threatening ventricular arrhythmias2,13 and in survivors of cardiac arrest14 is associated with arrhythmia reduction and improved survival. Monomorphic VT may be seen in patients with large AMIs; however, it is often attributable to reentrant rhythms from scar and not acute ischemia. Therefore, revascularization alone has not been shown to improve patient outcomes.15 Recommendation-Specific Supportive Text 1. In patients who survive cardiac arrest or have ventricular fibrillation or polymorphic VT, revascularization with CABG3 or PCI2 is associated with a lower likelihood of death.1,16 In patients with decreased left ventricular ejection fraction and ischemic heart disease amenable to CABG, the risk of sudden cardiac death is lower with CABG than with medical therapy.17,18 Although definitive conclusions may not be drawn from these studies because of the selection and survival biases inherent to these observational studies, revascularization may reduce the burden of polymorphic VT and ventricular fibrillation, resulting in improved survival. 2. In contrast to ventricular fibrillation and polymorphic VT, monomorphic VT in the nonacute setting is typically attributable to scar-related reentry or increased automaticity, rather than coronary artery ischemia.19 There are limited reports of AMIs presenting with monomorphic VT,20 isolated coronary artery ischemia causing isolated bundle-branch VT that is successfully treated with PCI,21 and exercise-induced VT associated with ischemia that resolves after CABG.19,22 Retrospective studies show an association of incomplete or unsuccessful revascularization of CAD with a higher VT burden and worse outcomes, but the association is most likely because of patient-level factors rather than the success of the intervention.1,9,23 In numerous large cohort studies, elective coronary artery revascularization alone has not been shown to reduce ventricular arrhythmias in stable patients.5-8 9.6 Revascularization in Patients With SCAD Recommendations for Revascularization in Patients With SCAD Referenced studies that support the recommendations are summarized in Online Data Supplement 22. COR LOE Recommendations 2b C-LD 1. In patients with SCAD who have hemodynamic instability or ongoing ischemia despite conservative therapy, revascularization may be considered if feasible.1-5 3: Harm C-LD 2. Routine revascularization for SCAD should not be performed.1-5 Synopsis SCAD is characterized by the interruption of the coronary artery intimal layer and intramural hematoma, causing vessel compression, and typically presenting as an ACS. Although most dissections will heal without intervention, a notable subset is associated with ongoing symptomatic ischemia, which can progress to complete occlusion. Treatment of patients with SCAD is challenging, and guidance from randomized trials is lacking. Observational studies indicate that most conservatively managed patients recover without further intervention. In patients with ongoing ischemia, vessel occlusion, or patient instability, selective revascularization may be necessary. However, unlike other forms of ACS, routine revascularization for patients with SCAD may not confer the same benefit. PCI wires may propagate the dissection, and balloons and stents can extend the hematoma and lead to vessel occlusion. CABG onto a dissected vessel or one with a propensity to dissect is challenging, and as many as 30% of patients have acute graft closure.5 The current state of the science and best practices for treating SCAD are described in the AHA scientific statement, which is based on an evaluation of retrospective studies and expert opinion.6 Recommendation-Specific Supportive Text 1. Although SCAD will often heal with conservative management, patients with ongoing ischemia, vessel occlusion, or instability may require urgent revascularization. In a retrospective study of 53 patients with SCAD and presenting with STEMI, Downloaded from http://ahajournals.org by on October 7, 2026