ACC/AHA With SCAI Issue 2021 Coronary Artery Revascularization Guideline

December 9, 2021—The 2021 joint guideline for coronary artery revascularization from the American College of Cardiology (ACC) and the American Heart Association (AHA), in partnership with the Society for Cardiovascular Angiography & Interventions (SCAI), has been published by Jennifer S. Lawton, MD, et al online in the Journal of the American College of Cardiology (with Executive Summary) and Circulation (with Executive Summary).

According to the ACC/AHA press release, patients undergoing coronary artery revascularization experience similar outcomes regardless of gender or race; therefore, the procedures should not be limited among women and adults from diverse racial or ethnic groups. Additionally, treatment decisions for coronary artery disease should be based on clinical indications and involve a multidisciplinary heart team that includes the patient and patient preferences.

Dr. Lawton, Chair of the guideline writing committee, commented in the societies’ press release, “Coronary artery disease remains a leading cause of morbidity and mortality globally, and coronary revascularization is an important therapeutic option when managing patients with this disease. Treatment recommendations in the guideline outline an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients’ interests.” Dr. Lawton is the Richard Bennett Darnall Professor of Surgery at Johns Hopkins Medicine and Chief of the Johns Hopkins Division of Cardiac Surgery in Baltimore, Maryland.

As summarized in the ACC/AHA press release, the guideline specifies that to ensure equity and reduce disparities of care, all revascularization treatment decisions should be based on clinical indications, regardless of sex, race, or ethnicity. There is no evidence that some patients with equivalent clinical indications benefit less than others; however, there is evidence that non-White patients are less likely to receive reperfusion therapy or an invasive strategy such as stenting or revascularization surgery.

Factors that are assessed to determine which procedure is best for a particular patient include the location and severity of the blockage, the patient’s clinical status and symptoms, the patient’s age, having type 2 diabetes or a weak heart, the number of vessels that are affected, and the risk involved for each procedure.

Furthermore, the guideline stated that determining the revascularization method and which treatment strategy is the best approach are not always clear for every patient, even when looking at the clinical indications. In these cases, a multidisciplinary heart team approach is recommended, including a cardiologist, cardiac surgeon, and other specialists. In addition to the heart team, the patient’s preferences, goals, support system, and understanding of their condition and potential outcomes should be considered.

Jacqueline E. Tamis-Holland, MD, the guideline writing committee Vice-Chair, stated in the press release, “The heart team has become an important paradigm in clinical practice, emphasizing the importance of team consensus on the optimal approach to revascularization.” Dr. Tamis-Holland is Professor of Medicine at the Icahn School of Medicine at Mount Sinai in New York, New York.

The guideline updates recommendations for intervention, surgery, and/or medical therapy in certain populations, including appropriate use of surgical revascularization or percutaneous revascularization for different disease states. Evidence has found that surgery is a reasonable recommendation to improve survival yet may not provide as strong a benefit over medication therapy as previously thought for patients with stable ischemic heart disease, normal left ventricular ejection fraction, and triple-vessel coronary artery disease. Evidence also shows that it is not certain that percutaneous coronary intervention (PCI) is able to improve survival over medical therapy in this population.

When PCI is the most appropriate treatment, recommendations are also made for radial access versus femoral when a clinician experienced in radial access is available. Femoral access remains the default for patients unable to receive radial artery catheterization because of anatomic limitations or because available clinicians are not experienced to perform radial access PCI.

The guideline also recommends a shorter 1- to 3-month duration of dual antiplatelet therapy (DAPT) after PCI as reasonable in select patients to reduce the risk of bleeding, based on the latest evidence. Previous recommendations were for 6 or 12 months of DAPT.

The ACC/AHA press release stated that this revascularization guideline complements the recently issued multisociety comprehensive clinical practice guideline on chest pain.

Additionally, it noted that the guideline represents a strategic effort by the ACC and AHA to approach guidelines from a real-practice perspective rather than solely topic-based guidelines. This guideline updates and consolidates the ACC/AHA 2011 coronary artery bypass graft surgery guideline and ACC/AHA/SCAI 2011 and 2015 PCI guidelines based on new evidence to provide a patient-centric, disease treatment approach. Several recommendations in the guidelines for stable ischemic heart disease (2012), ST-segment elevation myocardial infarction (2013), and non–ST-segment elevation acute coronary syndromes (2014) are also updated.