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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 e51 CLINICAL STATEMENTS AND GUIDELINES

62% underwent revascularization with PCI and 7.5% with CABG. Although rates of revascularization and PCI success were lower in patients with SCAD than in age-matched patients with STEMI attributable to atherosclerosis, overall survival was higher in patients with SCAD.3 A single-center, retrospective study of 189 patients with SCAD reported similar mortality rates at 5 years with a strategy of revascularization and with conservative care. In this cohort of patients, there was a higher rate of emergency or urgent CABG in patients with a patent vessel when they were treated with PCI versus conservative care.5 Although there are no RCTs comparing revascularization with conservative care in patients who have failed medical therapy, it is reasonable to consider revascularization in the presence of ongoing ischemia and hemodynamic instability. 2.	 Three large, single-center retrospective studies of patients undergoing PCI for SCAD described a failure rate of 35% to 53% and a need for urgent CABG of 9% to 13%. In these studies, conservatively treated patients experienced recurrent symptoms leading to revascularization only 2% to 10% of the time.1,2,5,7 Two meta-analyses evaluated the outcomes of patients who were treated conservatively compared with those who were acutely revascularized.1,4 There were no differences in short- or long-term mortality rate, MI, heart failure, or SCAD recurrence between the groups. However, in the 3 largest retrospective studies, there was a strong indication that there were more cardiovascular events in patients who had a first-line revascularization strategy. These studies are limited by selection and treatment biases, as revascularization was typically performed on higher-risk patients who were more likely to have an occluded artery.2,5,7 Nevertheless, despite these limitations, the data support a conservative management approach in clinically stable patients.

9.7 Revascularization in Patients With Cardiac

Allografts Recommendation for Revascularization in Patients With Cardiac Allografts

COR LOE Recommendation

2a C-LD 1.	 In patients with cardiac allograft vasculopathy and severe, proximal, discrete coronary lesions, revascularization with PCI is reasonable.1,2

Synopsis In patients after orthotopic heart transplantation, the onset of allograft vasculopathy presents a challenging treatment dilemma. Cardiac allograft vasculopathy is a major cause of death after the first year following orthotopic heart transplantation.3-5 Cardiac allograft vasculopathy is often diffuse and characterized by concentric and rapidly progressive intimal hyperplasia.6,7 Multiple immunologic and nonimmunologic risk factors have been linked to the accelerated progression of disease.8,9 Treatment options are limited, with retransplantation being the only definitive therapy for cardiac allograft vasculopathy.10 However, the scarcity of donor organs and worse outcomes, compared with initial transplantation, remain important limitations.11,12 Revascularization with PCI serves as a palliative treatment option in patients with focal disease.2,13 Studies have demonstrated lower periprocedural and intermediate-term mortality rates with stent implantation than with balloon angioplasty.9

Recommendation-Specific Supportive Text

1.	 Because the pathogenesis of cardiac allograft vasculopathy involves more diffuse intimal hyperplasia than focal atherosclerotic plaques, rates of death and MI remain higher in these patients.13,14 Use of PCI can be beneficial in patients with cardiac allograft vasculopathy who present with severe, proximal, discrete lesions.1,2 Although DES have demonstrated a clear benefit over bare-metal stents (BMS) for native CAD, patients with cardiac allograft vasculopathy were not included in these trials. However, there is a signal toward better outcomes with DES, especially with regard to the occurrence of restenosis.4,15,16

9.8 Revascularization in Patients Before

Transcatheter Aortic Valve Replacement (TAVR) 9.8.1. Special Considerations Before Transcatheter Valve Therapy Recommendations for revascularization in patients before TAVR should be accessed in the 2020 valvular heart disease guideline.1

9.9 Revascularization in Patients With

Anomalous Coronary Artery Coronary artery anomalies are among the most common congenital cardiovascular abnormalities. These include the anomalous aortic origin of a coronary artery, coronary fistula, and myocardial bridge. Natural history and presentation can be extremely variable, and much of the historical data from autopsy and surgical studies are now being more fully informed by increasing diagnostic capability.1,2 Sudden cardiac death and myocardial ischemia remain the major clinical concerns. The presentation and most appropriate management of these patients was reviewed extensively in the “2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Dis-

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