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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 e77 CLINICAL STATEMENTS AND GUIDELINES Synopsis Centers that provide coronary revascularization should participate in clinical data registries with the intent to review and continuously improve patient outcomes. Comparison of outcomes through the use of national databases allows individual- and program-level assessment of the care provided and the opportunity to enhance care with quality improvement initiatives. Collaboration with other centers allows peer review and discussion, as well as sharing and adoption of effective quality improvement measures. Recommendation-Specific Supporting Text 1. Participation in regional, state, or national registries that provide regular, risk-adjusted outcomes is beneficial in quality assessment and improvement. It allows participants to compare their performance to regional or national validated benchmarks, identify opportunities for improvement, and disseminate best practices.1-8 2. Quality and performance measures are defined by attributes related to structure, processes, and riskadjusted outcomes. Structural attributes include elements such as equipment, supplies, staffing, institution- and operator-level volumes, and electronic health records. Processes include strategies for appropriate patient selection; protocols for preand postprocedural care, procedural execution, and management of complications; and participation in databases and registries for benchmarking the performance of the program and individual operator. Risk-adjusted outcomes are the end result of these structures and processes of care, and when available, they may be more reliable measures of quality than the institutional-level and individual operator–level volumes.9-11 3. Smaller-volume coronary revascularization programs may benefit from affiliation and collaboration with larger volume programs. Standardized processes from both centers may be shared bidirectionally, and periodic exchange of staff will facilitate the transfer of best practices. Teaching conferences, as well as conferences on morbidity and mortality in both centers, may be shared via videoconferencing. In addition, residents and fellows may rotate between programs. Program size is typically defined by the specific database. 17 UNANSWERED QUESTIONS AND FUTURE DIRECTIONS The indications for revascularization and the approach to treatment in patients with CAD are generally based on evidence supporting benefit or lack thereof. Many rec- ommendations for revascularization are derived from the results of RCTs or observational studies of large registries or cohorts of patients that show consistent trends in outcomes. However, there are some patient subgroups and clinical scenarios for which there is a paucity of evidence to support a formal recommendation. In addition, in some circumstances, it is inappropriate or unethical to perform a randomized trial comparing 2 treatments. Furthermore, in some situations, even in the absence of strong evidence, recommendations are created on the basis of experiential consensus on best practices for the delivery of care. In these cases, further research is needed to inform practice, which would enable updated recommendations based on clinical trial results. 17.1 Special Populations 17.1.1. Underrepresented Racial and Ethnic Groups Despite advances in the identification of risk factors for CVD and the widespread use of evidence-based strategies to manage CVD, there are persistent sex, racial, and ethnic disparities in the delivery of care and in morbidity and mortality.1-8 Studies have shown that Black patients and patients of South Asian descent with CAD have worse outcomes than do White patients.2,4 Additionally, studies have reported worse outcomes in women than in men, although this finding is largely attenuated after adjustment for differences in baseline presentation and treatment.9 Recommendations for care in patients with CAD are often derived from RCT data with an unequal representation of women and racial and ethnic groups.10 Although a study’s findings might be extrapolated to such populations, it is unclear whether similar outcomes can be assumed from the reported trial results across all populations of patients. For this reason, in the planning of clinical trials, measures to ensure the enrollment of underrepresented racial and ethnic groups should be implemented to inform better care of patients.11 17.2 Special Clinical Situations 17.2.1. Left Ventricular Dysfunction RCT data support the use of CABG for the treatment of patients with coronary heart disease and left ventricular dysfunction to improve survival.12-14 Although the STICH trial reported improved outcomes with CABG compared with medical therapy, the advantage of CABG over medical therapy was independent of the presence or absence of myocardial viability.15-17 Critics have argued that the lack of a relative benefit of myocardial viability in predicting outcome with CABG was largely a result of the type of testing used.18 Many surgeons still use viability testing to guide decisions about revascularization in patients with severe left ventricular dysfunction. Nevertheless, in view of the lack of association of myocar- Downloaded from http://ahajournals.org by on October 7, 2026