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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 August 29, 2023 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline combines with biologically active heavy metal polyvalent cations, such as lead and cadmium, to form soluble complexes that can then be excreted.1 Very small trials conducted in patients with intermittent claudication and with CCD failed to show clinically relevant benefits.2–5 The first adequately powered trial of this intervention, TACT (Trial to Assess Chelation Therapy), randomized 1708 patients with previous MI to 40 infusions of chelation or placebo.6 The primary composite endpoint of total mortality, recurrent MI, stroke, coronary revascularization, or hospitalization for angina occurred in 222 (26%) patients in the chelation group and 261 (30%) patients in the placebo group (hazard ratio, 0.82 [95% CI, 0.69–0.99]; P=0.035). Among the 633 TACT patients with diabetes, chelation reduced the primary composite endpoint by 41% reduction (hazard ratio, 0.59 [95% CI, 0.44–0.79]; P=0.02 for interaction).6,7 EDTA is currently not approved by the FDA for preventing or treating cardiovascular disease. TACT2 (Trial to Assess Chelation Therapy 2) has randomized 1000 patients with diabetes and previous MI using the same treatment regimen as TACT and will report results in 2024.8 5 REVASCULARIZATION The topic of revascularization is evolving. We highlight certain management decisions in the next section. Recommendations are typically based on results of the major trials, meta-analyses, or both, covering varying amounts of the same material. We acknowledge that the trials do not cover the area consistently or address all questions comprehensively. Some trials begin with angiographically proven CAD (and a decision already made to proceed with revascularization), while others begin earlier in the clinical presentation. With this in mind, we have made a concerted effort to stay within the strongest evidence in shaping these recommendations for revascularization in patients with CCD. 5.1 Revascularization Recommendations for Revascularization Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations Goals of Revascularization 1 A 1 In patients with CCD and lifestyle-limiting angina despite GDMT and with significant coronary artery stenoses amenable to revascularization, revascularization is recommended to improve symptoms.*1–7 1 B-R 2 In patients with CCD who have significant left main disease or multivessel disease with severe LV dysfunction (LVEF ≤ 35%), CABG in addition to medical therapy is recommended over medical therapy alone to improve survival.*8–11 Cost Value Statement: Intermediate Value B-NR 3 In patients with CCD and multivessel disease with severe LV dysfunction, CABG added to optimal medical therapy is of intermediate economic value compared with medical therapy alone.12 2a B-R 4 In patients with CCD and multivessel CAD appropriate for either CABG or PCI, revascularization in addition to GDMT is reasonable to lower the risk of cardiovascular events such as spontaneous MI, unplanned urgent revascularizations, or cardiac death.*13–20 2a B-NR 5 In selected patients with CCD and significant left main stenosis for whom PCI can provide equivalent revascularization to that possible with CABG, PCI is reasonable to improve survival.*21 Decision-Making for Revascularization 1 A 6 In patients with CCD who have angina or an anginal equivalent, no previous evaluation for ischemia, and angiographically intermediate stenoses, the use of FFR or other proven nonhyperemic pressure ratios (eg, iFR) is recommended before proceeding with PCI.*2,22,23 Cost Value Statement: High Value B-NR 7 In patients with CCD undergoing coronary angiography without previous stress testing, the use of invasive FFR to evaluate angiographically intermediate coronary stenoses before proceeding with PCI is a high economic value intervention.24,25 1 B-NR 8 In patients with CCD with complex 3-vessel disease or for whom the optimal treatment strategy is unclear, a Heart Team approach that includes representatives from interventional cardiology and cardiac surgery is recommended to improve patient outcomes.*26–29 *Modified from the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.30 Synopsis The management of patients with CCD and stable angina is 3-fold: relief of symptoms, prevention of nonfatal events such as MI, and improving long-term survival. Medical therapy is often an effective option for these patients. However, revascularization results in a greater improvement in angina and QOL than does medical therapy alone. Similarly, revascularization among appropriate patients with CCD lowers the risk of cardiovascular death, MI and urgent revascularization, particularly among patients with multivessel disease.2,13,15,31 However, the effect of revascularization on improving survival in patients with CCD is more nuanced.32 Overall, multiple studies and subsequent meta-analyses have confirmed an overall null effect of revascularization on all-cause death for CCD, with few exceptions.15,19,33 Of note, patients in those studies tended to have a low atherosclerotic burden. Predictors of survival include anatomic and functional severity of the disease, LV function, and comorbidities such as diabetes and renal dysfunction.33 For Recommendations for Revascularization (Continued ) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026