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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline CLINICAL STATEMENTS AND GUIDELINES January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 inhibitor use. Compared with UFH, bivalirudin was not associated with improved rates of MACE, major bleeding, or stent thrombosis at 6 months. 4. Enoxaparin is considered a safe alternative to UFH.15,16 In the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors)14 and AtoZ (Aggrastat to Zocor)13 trials of patients with NSTE- ACS, enoxaparin was shown to be noninferior to UFH, with no difference in rates of death, MI, or major bleeding. In primary PCI, the ATOLL (Acute STEMI Treated With Primary Angioplasty and Intravenous Lovenox or UFH to Lower Ischemic and Bleeding Events)15 trial compared intravenous enoxaparin and UFH and showed a reduction in the main secondary endpoint (composite of death, recurrent ACS, and urgent revascularization) in the enoxaparin arm, without more bleeding. These findings have been supported by a subsequent large meta-analysis that included patients undergoing PCI for STEMI and NSTE-ACS, which showed a reduction in rates of all-cause death and bleeding.16 Almost all patients undergoing elective PCI who are administered enoxaparin (0.5 mg/kg IV) will have a peak anti-Xa level >0.5 IU/mL.31,39 5. In clinical trials, patients who were given upstream enoxaparin and then switched to UFH had more complications, which are attributed at least in part to stacking both medications at the time of PCI, even when heparin is administered as long as 10 hours after the last dose of enoxaparin.18,19 While these trials were performed prior to the widespread use of radial artery access, it is preferable to avoid the administration of UFH in patients that have received enoxaparin in the previous 12 hours to reduce risk of bleeding. 12 GENERAL PROCEDURAL ISSUES FOR CABG 12.1 Perioperative Considerations in Patients Undergoing CABG Recommendation for Perioperative Considerations in Patients Undergoing CABG Referenced studies that support the recommendation are summarized in Online Data Supplement 36. COR LOE Recommendation 1 B-NR 1. For patients undergoing CABG, establishment of multidisciplinary, evidence-based perioperative management programs is recommended to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, length of stay, and health care costs.1-3 Synopsis Previous recommendations with regard to perioperative management assessed the role of certain monitoring modalities to guide intraoperative and postoperative decision-making and also emphasized the use of fast-track cardiac anesthesia, which uses short-acting anesthetic agents to improve outcomes after CABG.4 More recently, cardiac surgical service lines have been encouraged to expand the scope of these efforts to develop multidisciplinary perioperative programs that incorporate bundled evidence-based surgical, anesthetic, and nursing interventions, including the targeted use of appropriate monitoring modalities, to optimize care and improve patient recovery. Recommendation-Specific Supporting Text 1. Fast-track cardiac anesthesia was extensively studied in the early 2000s and was found to reduce Table 10. Anticoagulant Dosing During PCI* Dosing of Parenteral Anticoagulants During PCI Drug Patient Has Received Previous Anticoagulant Therapy Patient Has Not Received Previous Anticoagulant Therapy UFH Additional UFH as needed (eg, 2000–5000 U) to achieve an ACT of 250-300 s* 70–100 U/kg initial bolus to achieve target ACT of 250–300 s* Enoxaparin For previous treatment with enoxaparin, if the last SC dose was administered 8–12 h earlier or if only 1 SC dose of enoxaparin has been administered, an IV dose of 0.3 mg/kg of enoxaparin should be given43-45 If the last SC dose was administered within the previous 8 h, no additional enoxaparin should be given 0.5–0.75 mg/kg IV bolus Bivalirudin For patients who have received UFH, repeat ACT If ACT is not in therapeutic range, then give 0.75 mg/kg IV bolus, then 1.75 mg/kg/h IV infusion 0.75 mg/kg bolus, 1.75 mg/kg/h IV infusion Argatroban 200 μg/kg IV bolus, then 15 μg/kg/min IV infusion 350 μg/kg, then 15 μg/kg/min IV infusion ACS indicates acute coronary syndrome; ACT, activated clotting time; CTO, chronic total occlusion; PCI, percutaneous coronary intervention; and UFH, unfractionated heparin. *Target ACTs for UFH dosing shown for HemoTec (GmbH, Switzerland) or I-Stat (Abbott) device. For Hemochron ACT (Werfen) devices, ACT goals are 50 s higher. In the case of CTO or ACS, consider higher target ACT. If IV glycoprotein IIb/IIIa receptor inhibitor is planned, target ACT 200–250 s.26,27,31,40-42 Downloaded from http://ahajournals.org by on October 7, 2026