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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 e26 CLINICAL STATEMENTS AND GUIDELINES COR Class of Recommendation CTO chronic total occlusion CVD cardiovascular disease DAPT dual antiplatelet therapy DES drug-eluting stent ECG electrocardiogram FFR fractional flow reserve GDMT guideline-directed medical therapy iFR instantaneous wave-free ratio IMA internal mammary artery ISR in-stent restenosis IVUS intravascular ultrasound LAD left anterior descending LIMA left internal mammary artery LOE Level of Evidence MACE major adverse cardiovascular events MI myocardial infarction NSTE-ACS non–ST-segment–elevation acute coronary syndrome NSTEMI non–ST-segment–elevation myocardial infarction OCT optical coherence tomography PCI percutaneous coronary intervention RCT randomized controlled trial SCAD spontaneous coronary artery dissection SIHD stable ischemic heart disease STEMI ST-segment–elevation myocardial infarction SVG saphenous vein graft SYNTAX Synergy Between PCI With TAXUS and Cardiac Surgery TAVR transcatheter aortic valve replacement UFH unfractionated heparin VT ventricular tachycardia 2 IMPROVING EQUITY OF CARE IN REVASCULARIZATION AND SHARED DECISION-MAKING 2.1 Improving Equity of Care in Revascularization Recommendation to Improve Equity of Care in Revascularization Referenced studies that support the recommendation are summarized in Online Data Supplement 1. COR LOE Recommendation 1 B-NR 1. In patients who require coronary revascularization, treatment decisions should be based on clinical indication, regardless of sex1-7 or race or ethnicity,8-10 and efforts to reduce disparities of care are warranted.11,12 Synopsis Health disparities by sex and race are evident across the spectrum of CVD in the United States,7,9,13-15 and mounting evidence demonstrates that social factors are strongly associated with cardiovascular health outcomes.16, 17 Differences in access to care, cardiovascular treatment, mortality rate, and readmission outcomes persist by important sociodemographic characteristics that include but are not limited to socioeconomic status, race, and ethnicity.18-22 African Americans,23-25 Hispanics,24 and South Asians26 (with substantial heterogeneity within Asian subgroups) have a higher prevalence of cardiovascular risk factors and crude mortality.16 Although access to health care remains a problem, even after entering into the health care system, women and non-White patients are less likely to receive reperfusion therapy, an invasive strategy, or revascularization9,13,27-37 and more likely to have worse outcomes.37-40 As compared with White male patients, women and Black patients with acute coronary syndrome (ACS) receive less guideline-based therapy in hospital and at discharge.27,32,41,42 Differences in comorbidities, health education, presentation, socioeconomic status, regional hospital capability and quality, and insurance and health care access15,28,29,35,37,43-48 contribute to the problem, but disparities can persist despite adjustment for these factors.7,30-32,49,50 In a study of patients with cardiac symptoms, clinicians were less likely to recommend cardiac catheterization to women and non-White patients than to White male patients, despite being given the exact same clinical vignette for White male patients.51 Continued vigilance against conscious and unconscious gender, racial, and ethnic discrimination and purposeful efforts to increase the implementation of guideline-based therapy for all patients, regardless of sex, race, or ethnicity, are needed. Recommendation-Specific Supportive Text After controlling for greater baseline comorbidities among patients undergoing revascularization, several observational studies have demonstrated that Black,28,52-54 Hispanic,24,50 and Asian55,56 patients have outcomes similar to those of White patients. Similarly, after controlling for baseline comorbidities and treatment strategy, most studies demonstrate similar outcomes in women and men.1-6 Post hoc analyses of randomized trials evaluating revascularization provide compelling evidence, inasmuch as enrolled patients are more similar and the decision to revascularize is protocol driven. In the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial, revascularization rates were lowest and mortality rates highest for Hispanics and 1.6 Abbreviations Continued Abbreviation Meaning/Phrase Downloaded from http://ahajournals.org by on October 7, 2026