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CLINICAL STATEMENTS AND GUIDELINES

August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

patients with CCD and LV dysfunction (particularly when LVEF is ≤35%) and for patients with left main disease, CABG has been shown to be superior to medical therapy alone for improving survival.8,10,11

Recommendation-Specific Supportive Text

1 In the COURAGE trial, patients initially random-

ized to GDMT who crossed over to early revascularization had worse baseline Seattle Angina Questionnaire scores. When compared with patients who were randomized to PCI, these patients experienced worse health status over the initial year of treatment and more unstable angina admissions.6 In the ISCHEMIA trial, the Seattle Angina Questionnaire summary scores were higher with an invasive strategy compared with a conservative strategy and sustained over 36 months of follow-up. Seattle Angina Questionnaire improvements were more pronounced among patients with greater frequency of baseline angina (daily/ weekly > monthly > none). Similarly, the probability of being angina-free was greater among participants who had angina at baseline but was minimal among those who were asymptomatic before randomization.1 In the ORBITA trial, PCI objectively reduced ischemia (assessed by dobutamine stress echocardiography), and although Seattle Angina Questionnaire scores did not differ among participants, PCI resulted in more patient-reported freedom from angina than placebo. Patients with greater ischemia burdens were more likely to have lower angina frequency score and freedom from angina with PCI than with the sham procedure.7 In a pooled analysis of FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) and FAME-2 (Fractional Flow Reserve Guided Percutaneous Coronary Intervention Plus Optimal Medical Treatment [OMT] Versus OMT), patients with lower FFR, greater improvement in FFR post-PCI and higher angina class at baseline were associated with the greatest magnitude of QOL improvement at 1 month and 1 year.34

2 Although older studies suggested a mortality ben-

efit with surgical revascularization, many recent studies and meta-analyses point to an overall null effect of revascularization on all-cause death for CCD.15,19,33,35 Important reasons include advances in medical management and a lower mortality rate with CCD in the contemporary era. For example, the annualized mortality rate in the medical therapy arm of ACME-2 (Angioplasty Compared to Medicine: Two-Vessel Disease) was 4.0%, but 1.0% in FAME-2 and 1.6% in ISCHEMIA.33 However, many of these trials also had high rates of crossover, and many patients had low angiographic complexity. Numerous technical advances in the field of revascularization also have occurred for CABG and PCI since some of these earlier trials were conducted.8,36,37 Two subgroups with mortality benefit of CABG over GDMT alone are patients with multivessel disease and moderate to severe LV dysfunction (ejection fraction ≤35%), and those with left main disease, both of which may occur concurrently.38 In the STICH trial, patients with ischemic cardiomyopathy and reduced LVEF (≤35%) who received CABG in addition to optimal medical therapy had improved survival at 10 years compared with patients who received medical therapy alone.11 In the REVIVED-BCIS 2 trial (Revascularization for Ischemic Ventricular Dysfunction: a Randomized Comparison of PCI [with Optimal Medical Therapy] Versus Optimal Medical Therapy Alone for Treatment of HF Secondary to Coronary Disease), PCI among patients with ejection fraction ≤35% did not improve MACE including survival at a median follow-up of 3.4 years.39 For patients with left main disease, the focus has been on comparing CABG and PCI in recent years; no recent trials are available that compare revascularization to GDMT alone for this indication. Further, most of the contemporary CCD trials have excluded patients with left main disease. Accordingly, the evidence to support revascularization is derived mainly from older RCTs, and no new data refute this evidence.8

3 Using data from the STICH trial, a decision-analytic

patient-level simulation model was developed to estimate the lifetime costs (in 2019 US dollars) and benefits (in QALYs) of CABG for ischemic cardiomyopathy from the US healthcare sector perspective and the lifetime analytic horizon. In this analysis, patients receiving CABG arm accrued 6.53 lifetime QALYs (95% CI, 5.70–7.53) and a lifetime cost of $140 059 (95% CI, $106 401–$180 992). In comparison, patients receiving medical therapy alone accrued 5.52 lifetime QALYs (95% CI, 5.06–6.09) and $74 894 lifetime cost (95% CI, $58 372–$93 541). Thus, the incremental costeffectiveness ratio for CABG compared with medical therapy alone was $63 989 per QALY gained, with 87% of the simulations producing incremental cost-effectiveness ratios ≤$100 000 per QALY gained. Thus, in patients with ischemic cardiomyopathy and reduced LV function, CABG has intermediate economic value ($50 000–$150 000/QALY gained) compared with medical therapy alone from the US healthcare sector perspective.12

4 Clinical events such as nonfatal MI, unstable

angina, and urgent revascularization are important for patients from a prognostic and a QOL perspective. Nonfatal MI rates appear to correlate with ischemia severity.40 Some ambiguity has

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