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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

been observed about the impact of revascularization on these clinical events. In MASS II (Medicine, Angioplasty, or Surgery Study), the 10-year rates of cardiac death were lower after CABG or PCI than after medical therapy alone.14 In ISCHEMIA, revascularization had a null effect on cardiovascular death and MI at 4 years overall, with a benefit noted among patients with most severe CAD (3-vessel severe stenosis [≥70%] or 2-vessel severe stenosis with proximal left anterior descending artery).40,41 At 7-year follow-up, a reduction in cardiovascular mortality with revascularization was observed.35 Moreover, in the ISCHEMIA trial, the incidence of procedural type 4a or type 5 MIs was increased with revascularization (20.1% of all MIs in the trial), but the incidence of late MI (spontaneous MI [type 1]), demand-induced MI (type 2), or MIs associated with stent thrombosis (type 4b) or with restenosis (4c) was reduced. A spontaneous MI was associated with a 2.4-fold increased hazard for all-cause death and a 3.4-fold increased hazard for cardiovascular mortality compared with no MI, whereas a procedural MI was not associated with all-cause or cardiovascular death.16 A contemporary meta-analysis of patients with CCD noted a reduction in cardiac death and spontaneous MI with revascularization compared with medical therapy alone. On meta-regression, cardiac death risk reduction was linearly associated with reductions in spontaneous MI and percentage of multivessel disease at baseline.15 Another contemporary metaanalysis confirmed a reduction in spontaneous MI with revascularization, but also noted an increase in procedural MI, with no improvement for MI overall with revascularization.33 However, revascularization reduced unstable angina (particularly among contemporary stent era trials) and unplanned revascularization in this and other meta-analyses.19

5 There are no RCTs directly comparing PCI to medi-

cal therapy for the treatment of left main disease. Most of the recent trials have focused on CABG versus PCI.42–45 Data from these trials and from subsequent meta-analyses suggest that patients with low-to-medium anatomic complexity left main disease that is equally suitable for surgical or percutaneous revascularization and predominantly with normal ejection fraction have similar survival with PCI and CABG 42,46–51 In addition, several registry studies have reported a survival advantage of PCI over medical therapy in patients with left main CAD,52 particularly using contemporary DES and PCI techniques.53–55 A network meta-analysis of 19 studies found that the survival advantage for PCI over medical therapy in patients with left main CAD was similar to the survival advantage for CABG over medical therapy.21 6 In FAME-2, among patients with CCD, FFR-guided

PCI (FFR, ≤0.8) of lesions ≥50% angiographic severity was superior to medical therapy alone in reducing the primary MACE endpoint, primarily driven by a reduction in the need for urgent revascularization.31 This benefit appeared to be sustained over 5 years of follow-up.2 FFR-guided PCI is also superior to angiography-guided PCI for reducing MACE rates among patients with multivessel CAD.23 More recently, iFR-guided PCI has been shown to be noninferior to FFR-guided PCI.22,56 iFR can be accomplished with shorter procedure times compared with FFR. Patients with FFR >0.8 or iFR >0.89 appear to have low event rates with medical therapy alone.57,58 Several other nonhyperemic pressure ratios, both wire-and angiography-based, have been developed and are undergoing further evaluation.59

7 In an economic evaluation of the FAME-2 trial

(888 patients with stable single-vessel or multivessel coronary artery disease with reduced fractional flow reserve, randomly assigned to PCI plus medical therapy or medical therapy alone), mean initial costs were higher in the PCI group ($9944 versus $4440; P<0.001) but by 3 years were similar between the 2 groups ($16 792 versus $16 737; P=0.94).60 The incremental cost-effectiveness ratio for PCI plus medical therapy compared with medical therapy alone was $17 300 per QALY gained at 2 years and $1600 per QALY gained at 3 years. Thus, the use of FFR in this context is a high economic value intervention (incremental cost-effectiveness ratio <$50 000 per QALY gained). These findings were robust in sensitivity analyses. This suggested that FFR-guided PCI of lesions is economically attractive compared with medical therapy alone in patients with stable coronary artery disease. Further, iFR has been shown to be noninferior to FFR, with economic evaluations suggesting that it has lower procedural costs.61 Thus, the use of iFRguided PCI is also likely to be a high value intervention (<$50 000/QALY gained) in this context. 8.	 A multidisciplinary Heart Team, involving an inter-

ventional cardiologist, cardiac surgeon, and other cardiovascular specialists, has become a critical component of the revascularization decision. Ideal situations for Heart Team consideration include patients with complex coronary disease/multivessel disease, comorbid conditions that could impact the success of the revascularization strategy, and other clinical or social situations that may impact outcomes. Treatment decisions should be patient-centered, incorporate patient preferences and goals, and include shared decision-making between the clinicians and the patients. For example, there may be patients who may prefer revascularization even if not on GDMT.

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