Clinical Update

ADAPTED FROM:
2021 ACC/AHA/SCAI Guideline of
Coronary Artery Revascularization
 CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡
CLASS 1 (STRONG) Benefit LEVEL A
>>> Risk
• High-quality evidence‡ from more than 1 RCT
Suggested phrases for writing recommendations: • Meta-analyses of high-quality RCTs
• Is recommended • One or more RCTs corroborated by high-quality registry studies
• Is indicated/useful/effective/beneficial
LEVEL B-R
Table 1. • Should be performed/administered/other
• Comparative-Effectiveness Phrases†: (Randomized)

Applying ACC/AHA
− Treatment/strategy A is recommended/indicated in preference to
• Moderate-quality evidence‡ from 1 or more RCTs
treatment B
• Meta-analyses of moderate-quality RCTs
− Treatment A should be chosen over treatment B
Class of CLASS 2a (MODERATE) Benefit
LEVEL B-NR
(Nonrandomized)
Recommendation and
>> Risk
• Moderate-quality evidence‡ from 1 or more well-designed, well-
Suggested phrases for writing recommendations:
executed nonrandomized studies, observational studies, or
Level of Evidence to • Is reasonable
• Can be useful/effective/beneficial
registry studies
• Meta-analyses of such studies

Clinical Strategies,
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is probably recommended/indicated in preference LEVEL C-LD (Limited
to treatment B Data)
Interventions, − It is reasonable to choose treatment A over treatment B

CLASS 2b (Weak) Benefit

• Randomized or nonrandomized observational or registry studies

Treatments, or ≥ Risk
with limitations of design or execution
• Meta-analyses of such studies
• Physiological or mechanistic studies in human subjects
Diagnostic Testing in Suggested phrases for writing recommendations:
• May/might be reasonable
• May/might be considered
LEVEL
COR and LOEC-EO
are determined independently (any COR may be paired with (Expert
any LOE).

Patient Care • Usefulness/effectiveness is unknown/unclear/uncertain or not well-

established
Opinion) with LOE C does not imply that the recommendation is weak. Many
A recommendation
important clinical questions addressed in guidelines do not lend themselves to clinical
Consensus
• Although
trials. of expert
RCTs are opinion
unavailable, based
there may be aon
veryclinical experience.
clear clinical consensus that a

(Updated May 2019)* CLASS 3: No Benefit (MODERATE)

Risk
Benefit =
particular test or therapy is useful or effective.
*The outcome or result of the intervention should be specified (an improved clinical
outcome or increased diagnostic accuracy or incremental prognostic information).
†For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only),
Suggested phrases for writing recommendations: studies that support the use of comparator verbs should involve direct comparisons of the
• Is not recommended treatments or strategies being evaluated.
• Is not indicated/useful/effective/beneficial ‡The method of assessing quality is evolving, including the application of standardized,
widely-used, and preferably validated evidence grading tools; and for systematic reviews,
• Should not be performed/administered/other the incorporation of an Evidence Review Committee. COR indicates Class of
Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR,
CLASS 3: Harm (STRONG) Risk > nonrandomized; R, randomized; and RCT, randomized controlled trial.
Benefit
Suggested phrases for writing recommendations:
Lawton, J. S. et al. 2021
• Potentially ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation.
harmful 2
• Causes harm
• Associated with excess morbidity/mortality
 Improving Equity of Care in Revascularization

Health disparities by sex and race Women and non-White patients Women and
are evident across the spectrum are less likely to receive guideline- non-White patients derive
of CVD in the United States. based therapies. comparable benefit from
revascularization after controlling
for other factors.

In patients who require coronary revascularization, treatment decisions

should be based on clinical indication, regardless of sex or race or
ethnicity, and efforts to reduce disparities of care are warranted (Class
1).

Abbreviations: CVD indicates cardiovascular disease.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 3
Shared Decision-Making and Informed Consent

COR RECOMMENDATIONS

In patients undergoing revascularization,

Informed Consent Patient-Centered Care decisions should be patient centered—that is,
Treatment & care options take considerate of the patient’s preferences and
Clinician provides the best
into consideration individual
1 goals, cultural beliefs, health literacy, and social
available evidence for
treatment options, including values & preferences determinants of health—and made in
the risks & benefits of each collaboration with the patient’s support system.
option
In patients undergoing coronary angiography or
revascularization, adequate information about
benefits, risks, therapeutic consequences, and
potential alternatives in the performance of
1 percutaneous and surgical myocardial
revascularization should be given, when
Shared Decision-Making feasible, with sufficient time for informed
decision-making to improve clinical outcomes.
A collaborative decision about treatment
or care is documented and shared with
relevant stakeholders

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 4
Factors for Consideration by the Heart Team
Coronary Procedural
Anatomy Comorbidities Factors Patient Factors
• Left main disease • Diabetes • Immunosuppression • Local and regional • Unstable presentation
• Multivessel • Systolic • Debilitating outcomes or shock
disease dysfunction neurological • Access site for PCI • Patient preferences
• High anatomic • Coagulopathy disorders • Surgical risk • Inability or
complexity • Valvular heart • Liver disease/ • PCI risk unwillingness to adhere
(i.e., bifurcation
disease cirrhosis to DAPT
disease, high SYNTAX
score)
• Frailty • Prior CVA • Religious beliefs
• Malignancy • Calcified aorta • Patient education,
• Aortic aneurysm knowledge, and
• ESRD understanding
• COPD

Guiding Principle: Ideal situations for Heart Team consideration include patients with complex
coronary disease, comorbid conditions that could impact the success of the revascularization
strategy, and other clinical or social situations that may impact outcomes.

Abbreviations: COPD indicates chronic obstructive pulmonary disease; CVA, cerebral vascular accident; DAPT, dual antiplatelet therapy;
ESRD, end-stage renal disease; PCI, percutaneous coronary intervention; and SYNTAX, Synergy Between PCI With TAXUS and Cardiac
Surgery.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 5
 Assessing Risk for Patients Undergoing CABG
In patients who are being considered for CABG, calculation of the
Society of Thoracic Surgeons (STS) risk score is recommended to help
stratify patient risk (Class 1).*

Prolonged Deep Sternal Prolonged Length

Reoperation Renal Failure Death Permanent Stroke
Ventilation Wound Infections of Stay

Risk Factors Not Quantified in the STS Score

Guiding Principle: In patients who are being considered for CABG,
Cirrhosis Meld calculation of the STS risk score is recommended to help stratify
Frailty Gait Speed patient risk. The MELD score, gait speed, and the MUST score may
help in patients with cirrhosis, frailty, and malnutrition
Malnutrition MUST respectively.

Abbreviations: CABG indicates coronary artery bypass grafting; MELD, Model for End-Stage Liver Disease;
MUST, Malnutrition Universal Screening Tool; and STS, Society of Thoracic Surgeons.
* See: https://www.sts.org/resources/risk-calculator
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 6
 Defining Lesion Severity
Lesion Severity

Coronary Coronary
Physiology IVUS SYNTAX Score Coronary
Physiology (Class 3: (Class 2a) (Class 2b) Angiography
(Class 1)
No Benefit)
In patients with angina or In stable patients with In patients with In patients with • Significant stenosis is
an anginal equivalent, angiographically intermediate stenosis of multivessel CAD, an defined as >70% for
undocumented ischemia, intermediate stenoses and the left main artery, assessment of CAD non-LMT and >50% for
and angiographically FFR >0.80 or iFR >0.89, PCI intravascular ultrasound complexity, such as the LMT.
intermediate stenoses, the should not be performed. (IVUS) is reasonable to SYNTAX score, may be • Intermediate stenoses
use of FFR or iFR is help define lesion severity. useful to guide (40-69%) generally
recommended to guide revascularization. warrant additional
the decision to proceed investigation.
with PCI.
• No standard cutoffs for
lesion length used to
classify a severe
stenosis.

Abbreviations: CAD indicates coronary artery disease; FFR, fractional flow reserve; iFR, instantaneous wave-free ratio; IVUS, intravascular
ultrasound; LMT, left main trunk; PCI, percutaneous coronary intervention; and SYNTAX, Synergy Between PCI With TAXUS and Cardiac
Surgery.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 7
Table 8. Patient Clinical Status Definitions to Guide
Revascularization
Cardiac function has been stable in the days-weeks before
Elective intervention. The intervention could be deferred without increased risk
of compromise to cardiac outcome.

Intervention is required during the same hospitalization to minimize

chance of further clinical deterioration. Examples include worsening sudden
Urgent chest pain, heart failure, acute myocardial infarction, anatomy, intra-aortic
balloon pump, unstable angina, with intravenous nitroglycerin, or rest
angina.
Patients requiring emergency intervention will have ongoing, refractory,
unrelenting cardiac compromise, with or without hemodynamic instability,
Emergency and not responsive to any form of therapy except cardiac intervention. There
should be no delay in providing operative intervention.

Patients requiring emergency/salvage intervention are those who require

Emergency/s cardiopulmonary resuscitation in route to intervention, before induction of
alvage anesthesia or who require extracorporeal membrane oxygenation to maintain
life.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 8
Revascularization of Infarct Artery in STEMI to Improve
Survival/Clinical Outcomes
Patient with STEMI
PCI if… CABG if…
• ischemic symptoms for <12 hr (1) • mechanical complications:
– ventricular septal rupture
• failed reperfusion after fibrinolytic – mitral valve insufficiency due to papillary muscle infarction
• therapy, then rescue PCI (1) or rupture
– free wall rupture) (1)
• cardiogenic shock or hemodynamic instability (1)
• cardiogenic shock or hemodynamic instability (1)
• Fibrinolytics w/ angiography 3 to 24 hr with PCI intent
(2a) If PCI is not feasible or successful, with a large area of
• stable &12 to 24 hr after symptom onset (2a) myocardium at risk (2a)

• ongoing ischemia, acute severe HF, or life-threatening

arrhythmia (2a) In STEMI, emergency CABG should NOT be performed after
failed primary PCI: In absence of ischemia or large area of
In asymptomatic stable STEMI w/ total occlusion >24 hr after myocardium at risk, or If surgical revascularization is not
symptom onset & no severe ischemia, PCI should not be feasible because of a no-reflow state or poor distal targets.
performed. (3:No Benefit) (3:Harm)

Abbreviations: CABG indicates coronary artery bypass grafting; HF, heart failure; hr, hour; MI, myocardial infarction;
PCI, percutaneous coronary intervention; STEMI, ST-segment–elevation myocardial infarction; and w/, with.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 9
Revascularization of Non–Infarct-Related Coronary Artery
Lesions in STEMI

Patients without significant

comorbidities with large non-
infarct vessels

In selected multivessel disease, after successful low-complexity multivessel disease, PCI of

hemodynamically stable primary PCI, staged PCI of a a non-infarct artery stenosis may be
patients with STEMI and significant non-infarct artery stenosis considered at time of primary PCI to
… is recommended. (Class 1) reduce cardiac events. (Class 2b)

in selected patients with complex complicated by cardiogenic shock, routine PCI of a

In STEMI… multivessel non-infarct artery disease, non-infarct artery at time of primary PCI should
after successful primary PCI, elective NOT be performed due to higher risk of death or
CABG is reasonable. (Class 2a) renal failure. (Class 3:Harm)

Abbreviations: CABG indicates coronary artery bypass grafting; MI, myocardial infarction;
PCI, percutaneous coronary intervention; and STEMI, ST-segment–elevation myocardial infarction.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 10
 Figure 5. Recommendations Timing of Invasive Strategy in
NSTE-ACS
NSTE-ACS

Guiding Principle:
In initially stabilized Revascularization in the
At high risk
Cardiogenic shock Refractory angina or patients who are at context of NSTE-ACS
(e.g., GRACE score*
hemodynamic instability >140) for clinical events intermediate or low risk for
clinical events should consider clinical
stability, risk of
recurrent event(s),
coronary anatomy, and
Immediate invasive Early invasive Invasive strategy with
strategy (1) strategy within 24 intent to perform degree of myocardium
hours (2a) revascularization before at risk.
hospital discharge
(2a)

*https://www.mdcalc.com/grace-acs-risk-mortality-calculator
Abbreviations: GRACE indicates Global Registry of Acute Coronary Events; and NSTE-ACS, non–ST-segment–elevation acute coronary syndrome

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 11
 Figure 6. Revascularization in Patients With SIHD
Indications to SIHD Anatomic indications
improve symptoms to improve survival
Refractory angina
YES NO
on medical therapy?

Revascularization YES Left main disease? NO

(1)
Significant left main Multivessel CAD with
YES stenosis & high anatomic NO YES anatomy suitable for PCI NO
complexity CAD? or CABG?
GMDT
YES Suitable candidate NO Ischemic cardiomyopathy
for CABG? CABG PCI YES NO
EF< 50%?
CABG Heart Team (1) (2a)
(1) Discussion (1) EF>50% and
Suitable candidate triple-vessel
YES NO disease
for CABG?
GMDT with or
Heart Team
w/o PCI EF 35%
EF<35% Discussion (1)
to 50% CABG PCI
(2b) (2b)
CABG CABG GMDT with or
(1) (2a) w/o PCI

Abbreviations: CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; EF, ejection fraction;
GDMT, guideline-directed medical therapy; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart
disease.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 12
Revascularization Based Approach to Improve Mortality Compared with
Medical Therapy in SIHD
Patient Subsets Deriving Class I Benefits of Revascularization
COR RECOMMENDATIONS

1 Left ventricular dysfunction and multivessel CAD with severe LVEF<35%, CABG is recommended (Class 1)

1 Left main CAD with significant left main stenosis, CABG is recommended (Class 1)

Patient Subsets Deriving Class 2a or 2b Recommendations

COR RECOMMENDATIONS
2a Left ventricular dysfunction and multivessel CAD with mild-to-moderate LVEF 35%–50%, CABG is recommended (Class 2a)

2a Left main CAD in selected patients: if PCI can provide equivalent revascularization to that possible with CABG, PCI is reasonable (Class 2a)

Multivessel CAD: normal EF, significant stenosis in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for CABG, CABG
2b may be reasonable to improve survival (Class 2b)
Multivessel CAD: normal EF, significant stenosis in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for PCI, the
2b usefulness of PCI to improve survival is uncertain (Class 2b)
Stenosis in the proximal LAD artery: normal LVEF and significant stenosis in the proximal LAD, the usefulness of coronary revascularization to improve
2b survival is uncertain (Class 2b)

Abbreviations: CABG indicates coronary artery bypass grafting; EF, ejection fraction; LAD, left anterior descending
artery; LVEF, left ventricle ejection fraction; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart
disease.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 13
Revascularization Based Approach to Improve Mortality Compared with
Medical Therapy in SIHD
Patient Subsets Deriving Class 3 Recommendations
COR RECOMMENDATIONS

Single- or double-vessel disease not involving the proximal LAD: normal LVEF, and 1- or 2-vessel CAD not involving the proximal LAD, coronary
3 revascularization is not recommended to improve survival (Class 3: No Benefit)

Single- or double-vessel disease not involving the proximal LAD: with >1 coronary arteries not anatomically or functionally significant (<70%
3 diameter of non–left main coronary artery stenosis, FFR >0.80), coronary revascularization should NOT be performed with the primary or sole intent
to improve survival (Class 3: Harm)

Abbreviations: CABG indicates coronary artery bypass grafting; EF, ejection fraction; LAD, left anterior descending
artery; LVEF, left ventricle ejection fraction; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart
disease.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 14
Revascularization Approach to Reduce Cardiovascular Events in SIHD
Compared with Medical Therapy
COR RECOMMENDATIONS
In patients with SIHD and multivessel CAD appropriate for either CABG or PCI, revascularization is reasonable
2a to lower the risk of cardiovascular events such as spontaneous MI, unplanned urgent revascularizations, or
cardiac death.

Revascularization Approach to Improve Symptoms

COR RECOMMENDATIONS
In patients with refractory angina despite medical therapy and with significant coronary artery stenoses
1 amenable to revascularization, revascularization is recommended to improve symptoms.

Abbreviations: CABG indicates coronary artery bypass grafting; EF, ejection fraction; LAD, left anterior descending
artery; LVEF, left ventricle ejection fraction; PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart
disease.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 15
PCI vs CABG in Patients with COMPLEX DISEASE
Patients with Complex Disease
COR RECOMMENDATIONS Severe
tortuosity

In patients who require revascularization for significant left main CAD with high-
1 complexity CAD, it is recommended to choose CABG over PCI to improve survival. Thrombotic Heavy
lesion calcification

In patients who require revascularization for multivessel CAD with complex or diffuse
2a CAD (e.g., SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a Complex
survival advantage. CAD
Aorto-ostial Complex
stenosis bifurcation
Guiding Principle:
CABG improves survival compared with PCI in patients Trifurcation
lesion
with left main and complex CAD.

Abbreviations: CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; PCI , percutaneous
coronary intervention; and SYNTAX, synergy between percutaneous coronary intervention with Taxus and cardiac
surgery.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 16
PCI vs CABG in Patients with COMPLEX DISEASE
Patients With Diabetes

Diabetes with Appropriate candidate for CABG with LIMA to LAD is

multivessel CAD CABG recommended (Class 1)

COR RECOMMENDATIONS
2a PCI can be useful in diabetics who have multivessel CAD and are poor candidates for surgery.

PCI may be considered to reduce MACO in diabetics with LM stenosis and low/intermediate complexity
2b CAD.

Guiding Principle:
CABG compared to PCI has a benefit in mortality
and repeat revascularizations in diabetics.

Abbreviations: CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; LAD, left anterior descending artery;
LIMA, left internal mammary artery; LM, left main artery; and MACO, major adverse cardiovascular outcomes.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 17
PCI vs CABG in Patients with COMPLEX DISEASE
Patients with previous CABG
Previous CABG

Patent LIMA to LAD who need repeat Refractory angina on GDMT

Complex CAD
revascularization attributable to LAD disease

Is PCI feasible? It is reasonable to choose CABG It may be reasonable to

over PCI* (Class 2a) choose CABG over PCI*
(Class 2a)
It is reasonable to choose PCI
over CABG (Class 2a) * When an IMA can be used as a conduit to the LAD.

Guiding Principle:
A Heart Team approach is important for those patients
with a prior history of CABG requiring
revascularization.
Abbreviations: CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; GDMT, guideline-directed medical
therapy; IMA, internal mammary artery; LIMA, left internal mammary artery; and PCI, percutaneous coronary intervention.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 18
Revascularization in Special Populations and
Situations

Pregnant Patients
COR RECOMMENDATIONS
1. In pregnant patients with STEMI not caused by SCAD, it is reasonable to perform primary PCI as the preferred
2a revascularization strategy.
2. In pregnant patients with NSTE-ACS, an invasive strategy is reasonable if medical therapy is ineffective for the management of
2a life-threatening complications.

Older Patients
COR RECOMMENDATIONS
1. In older adults, as in all patients, the treatment strategy for CAD should be based on an individual patient’s preferences,
1 cognitive function, and life expectancy.

Abbreviations: AKI indicates acute kidney injury; CAD, coronary artery disease; CKD, chronic kidney disease; NSTE-ACS, Non-ST segment elevation acute
coronary syndrome; PCI, percutaneous coronary intervention; SCAD; spontaneous coronary artery dissection; and STEMI, ST segment elevation myocardial
infarction
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 19
Revascularization in Special Populations and
Situations

Chronic Kidney Disease

COR RECOMMENDATIONS
1. In patients with CKD undergoing contrast media injection for coronary angiography, measures should be taken to minimize the
1 risk of contrast-induced AKI.

2. In patients with STEMI and CKD, coronary angiography and revascularization are recommended, with adequate measures to
1 reduce the risk of AKI.

3. In high-risk patients with NSTE-ACS and CKD, it is reasonable to perform coronary angiography and revascularization, with
2a adequate measures to reduce the risk of AKI.

4. In low-risk patients with NSTE-ACS and CKD, it is reasonable to weigh the risk of coronary angiography and revascularization
2a against the potential benefit.

3: No 5. In asymptomatic patients with stable CAD and CKD, routine angiography and revascularization are not recommended if there is
Benefit no compelling indication .

Abbreviations: AKI indicates acute kidney injury; CAD, coronary artery disease; CKD, chronic kidney disease; NSTE-ACS, Non-ST segment elevation acute
coronary syndrome; PCI, percutaneous coronary intervention; SCAD; spontaneous coronary artery dissection; and STEMI, ST segment elevation myocardial
infarction
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 20
Best Practices in Cath Lab for Patients with CKD
Undergoing Angiography
RECOMMENDATIONS
Assess the risk of contrast-induced
Use radial artery if feasible.
AKI before the procedure.

Delay CABG in stable patients after

Administer adequate
angiography beyond 24 hours when
preprocedural hydration.
clinically feasible.
Record the volume of contrast
Do not administer N-acetyl-L-cysteine to
media administered, and
prevent contrast-induced AKI.
minimize contrast use.

Do not give prophylactic renal

Pretreat with high-intensity
replacement therapy.
statins.

Abbreviations: AKI indicates acute kidney injury; CABG, coronary artery bypass grafting; and CKD, chronic kidney disease.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 21
Revascularization in Special Populations and
Situations
Reducing Ventricular Arrhythmias
Patients with SCAD
COR RECOMMENDATIONS
COR RECOMMENDATIONS
1. In patients with ventricular fibrillation, polymorphic
1. In patients with SCAD who have hemodynamic ventricular tachycardia (VT), or cardiac arrest,
instability or ongoing ischemia despite 1 revascularization of significant CAD is
2b conservative therapy, revascularization may be recommended to improve survival.
considered if feasible.
2. In patients with CAD and suspected scar-mediated
3: Harm
2. Routine revascularization for SCAD should not 3: No sustained monomorphic VT, revascularization is not
be performed. Benefit recommended for the sole purpose of preventing
recurrent VT.

Patients with Cardiac Allografts Before Noncardiac Surgery

COR RECOMMENDATIONS COR RECOMMENDATIONS
1. In patients with cardiac allograft vasculopathy 1. In patients with non–left main or noncomplex CAD
and severe, proximal, discrete coronary who are undergoing noncardiac surgery, routine
2a lesions, revascularization with PCI is
3: No coronary revascularization is not recommended
reasonable. Benefit solely to reduce perioperative cardiovascular
events.
Abbreviations: AKI indicates acute kidney injury; CAD, coronary artery disease; CKD, chronic kidney disease; NSTE-ACS, Non-ST segment elevation acute
coronary syndrome; PCI, percutaneous coronary intervention; SCAD; spontaneous coronary artery dissection; and STEMI, ST segment elevation myocardial
infarction
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 22
General Procedural Issues for PCI:
Procedure Considerations
Vascular Access for Stent Selection in Intravascular Imaging in PCI
PCI PCI
PCI in ACS PCI in SIHD DES should be used in IVUS and OCT can be useful for
preference to BMS (Class I) procedural guidance (2a)

Radial Approach (Class I)

Significant reduction in: • LM and complex coronary
artery stenting
• MI
È30-day rates: È30-day rates: , target ofvessel
• Mechanism stent failure
• Restenosis
• Death • Bleeding •revascularization.
Lesion preparation
• Non-fatal MI • Vascular • Acute stent thrombosis
• Stent sizing and expansion
and CVA complications
• Evaluate complications
• Non-major
bleeding Compared with angiographic-
guided PCI at 3 years, decreased
MACE, TVR, TLR

Abbreviations: ACS indicates acute coronary syndrome; BMS, bare metal stent; CVA, cerebrovascular accident; DES, drug-eluting stent; IVUS,
intravascular ultrasound; LM, left main coronary artery; MACE, major adverse coronary events; MI, myocardial infarction; OCT, optical coherence
tomography; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; TLR, target lesion revascularization; and TVR, target
vessel revascularization.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 23
General Procedural Issues for PCI:
Clinical Circumstances

Thrombectomy
COR RECOMMENDATIONS • No significant reduction in CV death, MI, cardiogenic shock,
reinfarction, stent thrombosis or target lesion revascularization
3: No 1. In STEMI, routine aspiration thrombectomy • Increased risk of stroke
Benefit before primary PCI is not useful
• Selective use in patients with high thrombus burden can be
considered

Calcified Lesions
COR RECOMMENDATIONS

2a 1. In fibrotic or heavily calcified lesions, plaque modification with rotational atherectomy improves procedural success
2. Plaque modification with orbital atherectomy, balloon atherotomy, laser angioplasty, or intracoronary lithotripsy can
2b be considered in fibrotic and heavily calcified lesions to improve procedural success

Abbreviations: CV indicates cardiovascular; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 24
General Procedural Issues for PCI:
Clinical Circumstances
SVG Disease
COR RECOMMENDATIONS

2a 1. In PCI of a SVG, use of an embolic protection device can decrease risk of distal embolization

Increased periprocedural MI, no-reflow,

2a 2. PCI of the native coronary artery is preferred over SVG PCI if feasible stent thrombosis, TVR and death with SVG
PCI
3: No 3. PCI of chronically occluded SVG should not be performed
benefit

Treatment of ISR
COR RECOMMENDATIONS

1 1. For PCI of ISR, a DES should be used to improve outcomes

2a 2. CABG can be useful over repeat PCI to reduce recurrent events in symptomatic diffuse ISR

2b 3. Brachytherapy may be considered in recurrent ISR to improve symptoms

Abbreviations: CABG indicates coronary artery bypass grafting; DAPT, dual antiplatelet therapy, DES, drug-eluting stent; ISR, in-stent
restenosis; MI, myocardial infarction; PCI, percutaneous coronary intervention; SVG, saphenous vein graft; and TVR, target vessel
revascularization.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 25
General Procedural Issues for PCI:
Clinical Circumstances
Hemodynamic Support
COR RECOMMENDATIONS • RCT showed no benefit in the composite outcome of
1. Elective placement of a hemodynamic support device, such death, MI, CVA or repeat revascularization
2b as Impella or IABP, may be reasonable as an adjunct to PCI • Significant reduction in major procedure complications,
in select high-risk patients largely driven by improvement in hemodynamic
support

CTO Treatment
COR RECOMMENDATIONS • 80% procedural success
1. In patients with suitable anatomy and refractory angina • 1.3% 30-day mortality
2b despite medical therapy and treatment of non-CTO lesions, • 4.8% perforation
the benefit of CTO PCI to improve symptoms is uncertain • Euro CTO: significant reduction in angina frequency and
improved QOL
• DECISION-CTO: no difference in symptoms or clinical outcomes

Abbreviations: CTO indicates chronic total occlusion; CVA, stroke; IABP, intra-aortic balloon pump; MI, myocardial infarction;
PCI, percutaneous coronary intervention; QOL, quality of life; and RCT, randomized controlled trial.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 26
Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI
COR RECOMMENDATIONS

1 1. In patients undergoing PCI, a loading dose of aspirin followed by a daily dosing is recommended.

1 2. In patients with ACS undergoing PCI, a loading dose of P2Y12 inhibitor followed by a daily dosing is recommended.

1 3. In patients with SIHD undergoing PCI, a loading dose of clopidogrel, followed by daily dosing is recommended.
4. In patients undergoing PCI within 24 hours after fibrinolytic therapy, a loading dose of 300 mg of clopidogrel,
1 followed by daily dosing, is recommended.
5. In patients with ACS undergoing PCI, it is reasonable to use ticagrelor or prasugrel in preference to clopidogrel to
2a reduce ischemic events, including ST
6. In patients undergoing PCI who are P2Y12 inhibitor naïve, intravenous *cangrelor may be reasonable to reduce
2b periprocedural ischemic events
*(See section 11.2. Intravenous P2Y12 Inhibitors in Patients Undergoing PCI for synopsis of rationale)

3: Harm 7. In patients undergoing PCI who have a history of stroke or TIA, prasugrel should not be administered

Abbreviations: ACS indicates acute coronary syndrome; PCI , percutaneous coronary intervention;
SIHD, stable ischemic heart disease; ST, stent thrombosis; and TIA, transient ischemic attack.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 27
Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI

COR RECOMMENDATIONS
1. In patients with ACS undergoing PCI with large thrombus burden, no reflow or slow flow, intravenous glycoprotein
2a IIb/IIIa inhibitor agents are reasonable to improve procedural success.
2. In patients with SIHD undergoing PCI, the routine use of an intravenous glycoprotein IIb/IIIa inhibitor is not
3: Harm recommended

Guiding Principle:
The benefit of Gp IIb/IIIa inhibitors has decreased with
shorter revascularization times and potent DAPT.

Abbreviations: ACS indicates acute coronary syndrome; PCI , percutaneous coronary intervention;
SIHD, stable ischemic heart disease; ST, stent thrombosis; and TIA, transient ischemic attack.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 28
Anticoagulation in Patients Undergoing PCI
COR RECOMMENDATIONS
1. In patients undergoing PCI, administration of intravenous unfractionated heparin is useful to reduce ischemic
1 events.
2. In patients with heparin-induced thrombocytopenia undergoing PCI, bivalirudin or argatroban should be used to
1 replace UFH to avoid thrombotic complications.
2b 3. In patients undergoing PCI, bivalirudin may be a reasonable alternative to UFH to reduce bleeding.
4. In patients treated with upstream subcutaneous enoxaparin for unstable angina or NSTE-ACS, intravenous
2b enoxaparin may be considered at the time of PCI to reduce ischemic events.
5. In patients on therapeutic subcutaneous enoxaparin, in whom the last dose was administered within 12 hours of
3: Harm PCI, UFH should not be used for PCI and may increase bleeding

Guiding Principle:
Antithrombotic therapy is a mainstay of treatment in
patients undergoing PCI.

Abbreviations: UFH indicates unfractionated heparin; NSTE-ACS, Non-ST elevation-acute coronary syndrome; and PCI, percutaneous coronary intervention.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 29
 Figure 7: Use of DAPT for Patients After PCI
Patients Undergoing PCI

SIHD ACS

DES BMS

0 mo
≥1 mo
aspirin plus
1 mo clopidogrel
Discontinue aspirin after
1-3 mo with continued P2Y12 ≥6 mo (Class 1) Discontinue aspirin after 1-3
monotherapy (Class 2a) aspirin plus month with continued P2Y12
clopidogrel monotherapy (Class 2a)
If high risk of bleeding or overt (Class 1)
≥12 mo
3 mo bleeding on DAPT, discontinuing
P2Y12 after 3mo may be reasonable aspirin plus
(Class 2b) clopidogrel,
or prasugrel, If high risk of bleeding or overt
6 mo or ticagrelor bleeding on DAPT, discontinuing
(Class 1) P2Y12 after 6mo may be reasonable
(Class 2b)
If no high risk of bleeding or If no high risk of bleeding or
significant overt bleeding on DAPT, significant overt bleeding on
>6 mo. DAPT may be reasonable DAPT, >1 mo DAPT may be
(Class 2b) reasonable (Class 2b)
12 mo
If no high risk of bleeding or significant
overt bleeding on DAPT, >1 y DAPT may
Abbreviations: BMS indicates bare metal stent; DAPT, dual antiplatelet therapy; DES, drug eluting stent; be reasonable (Class 2b)
PCI, percutaneous coronary intervention; and SIHD, stable ischemic heart disease.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 30
Antiplatelet Therapy in Patients with Atrial Fibrillation on
Anticoagulation After PCI

Patients with atrial fibrillation who are

undergoing PCI and are taking oral anticoagulant
therapy

Recommend discontinuing aspirin after 1-4 weeks When treated with DAPT or a P2Y12 inhibitor
while maintaining P2Y12 inhibitors in addition to monotherapy, it is reasonable to choose a non–
a non–vitamin K oral anticoagulant or warfarin vitamin K oral anticoagulant over warfarin (Class
(Class 1) 2a)

Reduce the risk of bleeding

Abbreviations: DAPT indicates dual antiplatelet therapy; and PCI, percutaneous coronary intervention.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 31
Antiplatelet Therapy in Patients After CABG

Patients undergoing CABG Selected patients undergoing CABG

(e.g. off-pump, high SYNTAX score)

Initiate aspirin (100-325 mg daily) within 6

Initiate DAPT with aspirin and
hours postoperatively and
ticagrelor or clopidogrel for 1 year
continue indefinitely
(Class 2b)
(Class 1)

Reduce saphenous vein graft occlusion and Improve vein graft patency compared with
adverse cardiovascular events aspirin alone

Abbreviations: CABG indicates coronary artery bypass grafting; and DAPT, dual antiplatelet therapy.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 32
Beta Blockers in Patients After Revascularization

Patients with SIHD and normal LV

function who receive complete Patients after
revascularization undergoing CABG

The routine use of chronic oral beta blockers

is not beneficial to reduce cardiovascular Beta blockers are recommended and should
events be started as soon as possible (Class 1)
(Class 3: No Benefit)

Reduce the incidence or clinical sequelae

of postoperative atrial fibrillation

Abbreviations: CABG indicates coronary artery bypass grafting; LV, left ventricle; and SIHD, stable ischemic heart disease.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 33
Focus on Perioperative Considerations in Patients
Undergoing CABG and Outcomes

For patients undergoing CABG,

establishment of multidisciplinary,
evidence-based perioperative
management programs is
recommended to optimize analgesia,
minimize opioid exposure, prevent
complications and to reduce time to
extubation, length of stay, and
healthcare costs. (Class 1)

Abbreviations: CABG indicates coronary artery bypass grafting; CNS, central nervous system; CV, cardiovascular disease; LOS, length of
stay; SIHD, stable ischemic heart disease; STEMI, ST segment elevation myocardial infarction; and TEE, transesophageal echo.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 34
 Bypass Conduits in Patients Undergoing CABG

Radial artery IMA (prefer left) BIMA

To LAD (Class 1)
Recommended in preference to a saphenous
vein conduit to graft the second most
important, significantly stenosed, non–LAD
vessel (Class 1) Improves
long-term outcomes
when procedure is
done by experienced
operators
(Class 2a)

Source: This Photo by Unknown Author is licensed under CC BY-SA

Source: This Photo by Unknown Author is licensed under CC BY-SA Source: https://vpjournal.net/article/view/3141

Click here for more best practices

Abbreviations: BIMA indicates bilateral internal mammary artery; IMA, internal mammary artery; LAD, left anterior descending; and SVG, saphenous vein graft..

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 35
 Patients Undergoing Other Cardiac Surgery and
Operative Approach

Significant Aortic Calcification

Valve, aortic, OR OR
other cardiac surgery Significant Pulmonary disease

Significant CAD Decrease stroke risk

Source: This Photo by Unknown

Author is licensed under CC BY- Source: This Photo by Unknown Author is
NC licensed under CC BY-NC

Off-pump or beating heart

Concomitant CABG
approach may be reasonable
(Class 1)
(Class 2a)

Abbreviations: CABG indicates coronary artery bypass grafting; and CAD, coronary artery disease.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 36
Use of Epiaortic Ultrasound in Patients Undergoing
CABG

In patients undergoing CABG, the routine use of epiaortic

ultrasound scanning can be useful to evaluate the
presence, location, and severity of plaque in the ascending
aorta to reduce the incidence of atheroembolic
complications
(Class 2a)

ü Superior to digital palpation or TEE

ü “Gold standard” for detection of presence, location,
and severity

Abbreviations: TEE indicates transesophageal echo; and US, ultrasound.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 37
Decrease Post-operative Deep Sternal Wound
Infections
Intraop + Postop Target Serum Glucose Level:
<180mg/dL
(Class 1)

Administer IV insulin
continuous infusion

AVOID hypoglycemia

Click here for more best practices

Abbreviations: IV indicates intravenous; and SWI, sternal wound infections.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 38
Perioperative Pharmacotherapy
Pre-op PRE-OP ANTI-PLATELET PLAN TO DECREASE RISK OF BLEEDING
Anti-platelet ASA, daily CONTINUE, if already taking (Class 1)

STOP At least 24 hrs, if URGENT (Class 1)

Clopidogrel & Ticagrelor STOP Ticagrelor at least 3d, if elective (Class 2a)
STOP Clopidogrel at least 5d, if elective (Class 2a)
STOP Prasugrel at least 7d, if elective (Class 2a)

Eptifibatide & Tirofiban STOP At least 4 hrs (Class 1)

Abciximab STOP At least 12 hrs (Class 1)

Anti- BB and Amiodarone can reduce the incidence of BB may reduce mortality or postop complications
Arrhythmics* post-op afib (Class 2a) (Class 2b)
Preop
* In patients with no contraindications to usage

Abbreviations: AFIB indicates atrial fibrillation; ASA, aspirin; BB, beta blockers; D, days; and HRS, hours.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 39
 Psychosocial Factors and Lifestyle Changes after
Revascularization
COR RECOMMENDATIONS
Cardiac 1. Following revascularization, home and center-based cardiac rehabilitation
Rehabilitation and 1 reduced death, hospital readmission and improves quality of life.
Education 1
2. After revascularization, patients should be educated about CVD risk factors
and their modification to reduce CV events.

COR RECOMMENDATIONS
Smoking Cessation 1. Following revascularization, behavioral interventions and pharmacotherapy
1 are recommended to maximize smoking cessation and reduce CV events.
2. Smoking cessation interventions should occur during the index hospitalization
1 for revascularization with at least on month supportive follow-up.

COR RECOMMENDATIONS
1. Cognitive behavioral therapy, psychological counseling, and/or
Psychological 1 pharmacological treatment can improve QOL and cardiac outcomes after
Interventions revascularization in patients with depression, anxiety or stress.
2. After revascularization, screening for depression and referral/ treatment
2b when indicated improves QOL and recovery.

Abbreviations: CV indicates cardiovascular; CVD, cardiovascular disease; and QOL, quality of life.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 40
Traditional and Non-Traditional Risk Factors for CVD
After revascularization, patients should be educated about CVD risk factors
and their modification to reduce CV events (Class 1).

Behavioral interventions
and pharmacotherapy
(NRT, varenicline, Cognitive behavioral
bupropion) (Class 1) therapy, psychological
counseling, and/or
pharmacological
» 2019 ACC/AHA Guideline treatment (Class 1)
on the Primary Prevention
of Cardiovascular Disease

» AHA’s Life’s Simple 7

program

Abbreviations: ASCVD indicates atherosclerotic cardiovascular disease; CV, cardiovascular; CVD, cardiovascular disease; and NRT, nicotine replacement therapy.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 41
Revascularization Outcomes
Revascularization centers should participate in clinical data registries to review and improve
patient outcomes.

With the goal of improving patient outcomes, it is recommended that cardiac surgery and PCI programs
participate in state, regional, or national clinical data registries and receive periodic reports of their risk-adjust
outcomes as a quality assessment and improvement strategy (Class 1).

With the goal of improving patient outcomes, is reasonable for cardiac surgery and PCI programs to have a QI
program that routinely:
1. reviews institutional quality programs and outcomes,
2. reviews individual operator outcomes,
3. provides peer review of difficult or complicated cases,
4. performs random case reviews. (Class 2a)

In asymptomatic stable STEMI w/ total occlusion >24 hr after symptom onset & no severe ischemia, PCI should not
be performed. (3:No Benefit)

Abbreviations: QI indicates quality improvement; and PCI, percutaneous coronary intervention.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 42
Unanswered Questions and Future Directions
Special Clinical Situations: Left Ventricular Dysfunction

Data from randomized control trials support

ü surgical revascularization in the setting of left

ventricular dysfunction to improve survival.

Although commonly used to guide

revascularization decisions, the role of

?
myocardial viability imaging (for example, with
PET or MRI) in guiding clinical practice is unclear.

Further research is needed into whether PCI can

improve survival in patients with systolic heart

?
failure.

Abbreviations: MRI indicates magnetic resonance imaging; PET, positron emission tomography; and PCI percutaneous coronary intervention.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 43
Special Clinical Situations: Nonatherosclerotic
Lesions
Spontaneous coronary Coronary artery aneurysms
Myocardial bridging
artery dissection
Expert consensus Coronary artery aneurysms can In cases of severe ischemia

ü
recommends conservative
care for most patients. ? be asymptomatic or lead to
ischemia, thrombosis, fistula
formation, or rupture. The ideal
? and significant myocardial
bridging, surgical approaches
are available, but the long-
Research is needed to timing and mode of intervention term risks and benefits are
understand optimal is unknown. uncertain.

?
management in patients
with ongoing symptoms,
hemodynamic instability,
or severely compromised
flow to a large myocardial
territory.

Source: https://resident360.nejm.org/clinical-pearls/spontaneous-coronary-artery-dissection

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 44
Unanswered Questions and Future Directions Special Clinical Situations:
Considerations in Bypass Grafting

Heart Team discussions are appropriate for

ü
management of acute graft failure, obstructive graft
disease, and PCI of native arteries via bypass grafts.

There are no data to determine the optimal

antithrombotic regimen of patients after ACS who

? undergo CABG and also have an indication for systemic

anticoagulation.

The roles of hybrid surgical/ percutaneous

revascularization in multivessel disease and the use of

? non-sternotomy surgical approaches remain unknown.

Abbreviations: ACS indicates acute coronary syndrome, CABG, coronary artery bypass grafting, and PCI percutaneous coronary intervention.
Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 45
Unanswered Questions and Future Directions Special Clinical Situations:
Completeness of Revascularization

Observational data have shown worse outcomes in patients with multivessel disease if

ü severe stenoses in major epicardial arteries are not revascularized during the
index procedure.

However, patients in these studies who underwent incomplete revascularization had more

ü significant comorbidities, and the motivations behind an individual operator's procedural

decisions are complex.

? It is reasonable to assume that improving perfusion to as large a myocardial territory as

possible is likely beneficial, but evidence from RCTs is lacking.

? RCTs are needed compare the outcomes of complete versus incomplete revascularization in
stable ischemic heart disease.

Abbreviations: RCT indicates randomized controlled trial.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 46
Special Clinical Situations:
Elective Revascularization prior to other Procedures

COR RECOMMENDATIONS
1. In patients undergoing TAVI with significant left main or proximal CAD with or without
2a angina, revascularization by PCI before TAVI is reasonable.

? Further research is needed to determine whether routine

revascularization prior to TAVR improves clinical outcomes.

ü It is common for a patient to be referred for revascularization in

preparation for solid organ transplantation.

?
Patients awaiting solid organ transplant are complex, and it remains
unclear whether revascularization prior to organ transplantation positively
impacts survival.

Abbreviations: CAD indicates coronary artery disease; PCI, percutaneous coronary intervention; and TAVI, transcatheter aortic valve implantation.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 47
Acknowledgments
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman in developing this translational
learning product in support of the ACC/AHA/SCAI Guideline for Coronary Artery Revascularization

Karen Deffenbacher, MD
Amit Goyal, MD
Madonna Lee, MD
Madeline Mahowald, MD
Manolo Rubio Garcia, MD
Hanjay Wang, MD

The American Heart Association requests this electronic slide deck be cited as follows:

Deffenbacher, K., Goyal, A., Lee, M., Mahowald, M., Garcia, M., Wang, H., Bezanson, J. L., & Antman, E. M. (2021).
Clinical Update; Adapted from: ACC/AHA/SCAI Guideline for Coronary Artery Revascularization [PowerPoint slides].
Retrieved from https://professional.heart.org/en/science-news

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 48
Appendix
Table 13. Best Practices for the Use of Bypass 3 Return to previous slide
Conduits in CABG

• Objectively assess palmar arch completeness and ulnar compensation before harvesting the radial artery. Use the arm with the best
ulnar compensation for radial artery harvesting.
• Use radial artery grafts to target vessels with subocclusive stenoses.
• Avoid the use of the radial artery after transradial catheterization.
• Avoid the use of the radial artery in patients with chronic kidney disease and a high likelihood of rapid progression to hemodialysis.
• Use oral calcium channel blockers for the first postoperative year after radial artery grafting.
• Avoid bilateral percutaneous or surgical radial artery procedures in patients with coronary artery disease to preserve the artery for
future use.
• Harvest the internal mammary artery using the skeletonization technique to reduce the risk of sternal wound complications.
• Use an endoscopic saphenous vein harvest technique in patients at risk of wound complications.
• Use a no-touch saphenous vein harvest technique in patients at low risk of wound complications.
• Use the skeletonized right gastroepiploic artery to graft right coronary artery target vessels with subocclusive stenosis if the operator
is experienced with the use of the artery.

Abbreviations: CABG indicates coronary artery bypass grafting.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 50
Table 14. Best Practices to Reduce Sternal Wound Infection 3 Return to previous slide
in Patients Undergoing CABG

• Perform nasal swab testing for Staphylococcus aureus (8).

• Apply mupirocin 2% ointment to known nasal carriers of S aureus (8).
• Apply preoperative intranasal mupirocin 2% ointment to those patients whose nasal culture or PCR result is unknown (8).
• Redose prophylactic antimicrobials for long procedures (>2 half-lives of the antibiotic) or in cases of excessive blood loss during CABG
(10, 11, 27).
• Measure perioperative HbA1c (31).
• Treat all distant extrathoracic infections before nonemergency surgical coronary revascularization (19).
• Advise smoking cessation before elective CABG surgery (7).
• Apply topical antibiotics (vancomycin) to the cut edges of the sternum on opening and before closing in cardiac surgical procedures
involving a median sternotomy (4, 32).
• Use skeletonized harvest of IMA in BIMA grafting (16).
• Do not continue prophylactic antibiotics beyond 48 hours (9, 11)

Abbreviations: CABG indicates coronary artery bypass grafting.

Lawton, J. S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Circulation. 51