New guideline advises not limiting coronary revascularization based on race, sex
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Coronary revascularization confers similar outcomes regardless of race, ethnicity or sex, so decisions on revascularization should be made based on clinical indications, according to a new guideline.
The American College of Cardiology and American Heart Association, in partnership with the Society for Cardiovascular Angiography and Interventions, issued the coronary artery revascularization guideline covering decisions on whether to perform PCI or CABG on a patient with CAD. It updates the 2011 CABG guidelines and 2015 PCI guidelines and is intended as a complement to the recently issued chest pain guidelines.
Evidence-based approach
Source:
Johns Hopkins Medicine.
Reprinted with permission.
“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,” Jennifer S. Lawton, MD, FAHA, guideline writing committee chair, the Richard Bennett Darnall Professor of Surgery and chief of the Johns Hopkins Division of Cardiac Surgery and director of the Cardiac Surgery Research Laboratory at Johns Hopkins Medicine, said in a press release. “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.”
The guideline authors wrote that there is no evidence that revascularization outcomes differ by race, ethnicity for sex, but patients who have CAD and are not white are less likely to receive reperfusion therapy, PCI with stenting or CABG than white patients with CAD.
Therefore, the authors wrote, revascularization decisions should be made based on clinical factors such as location of occlusion, severity of occlusion, clinical status and symptoms, diabetes status, HF status, number of occluded vessels and the risks for PCI or CABG to the individual patient.
The committee recommended that for patients for which a decision based on clinical factors is not clear, a multidisciplinary heart team consisting of a cardiologist, a cardiac surgeon and other specialists should be consulted, and that the preferences, goals, support system and understanding of the patient should be considered.
“The Heart Team has become an important paradigm in clinical practice, emphasizing the importance of team consensus on the optimal approach to revascularization,” Jacqueline E. Tamis-Holland, MD, FACC, FAHA, FSCAI, guideline writing committee vice chair and professor of medicine at the Icahn School of Medicine at Mount Sinai, said in the release.
Take-home messages
When PCI is the decision, transradial access is preferred over transfemoral access if feasible regardless of whether the patient has ACS or stable CAD, and certain patients should receive shorter duration of dual antiplatelet therapy than previously recommended, the authors wrote.
“After consideration of recurrent ischemia and bleeding risks, select patients may safely transition to P2Y12 inhibitor monotherapy and stop aspirin after 1 to 3 months of dual antiplatelet therapy,” Lawton and colleagues wrote.
In patients with left main disease, surgical revascularization is preferred over medical therapy in most patients, and PCI may be considered over medical therapy in some without anatomic complexity, according to the authors.
In patients with stable ischemic heart disease, normal left ventricular ejection fraction and three-vessel CAD, surgery is a reasonable option to improve survival, though whether PCI can improve survival in these patients is unclear, so decisions should be made by a heart team and driven by disease complexity and feasibility of procedures, the authors wrote.
In CABG procedures, the radial artery is preferred as a conduit over the saphenous vein to bypass the second-most important target vessel, according to the document.
In patients with STEMI and multivessel CAD, staged PCI to revascularize a nonculprit vessel with significant stenosis in recommended in some cases, whereas revascularization of nonculprit vessels at the time of primary PCI may be considered in some patients with noncomplex disease, the authors wrote, noting PCI of nonculprit arteries should not be performed in patients with cardiogenic shock.
The heart team should be involved with revascularization decisions for patients with diabetes and multivessel CAD, though CABG is recommended for patients with diabetes and three-vessel disease unless they are poor candidates for surgery, in which case PCI may be considered, Lawton and colleagues wrote.
Patients undergoing CABG should have their surgical risk calculated by the Society of Thoracic Surgeons score as opposed to their SYNTAX score, according to the authors.
References:
- Lawton JS, et al. Circulation. 2021;doi:10.1161/CIR.0000000000001038.
- American College of Cardiology, American Heart Association Issue Coronary Artery Revascularization Guideline. https://www.acc.org/Latest-in-Cardiology/Articles/2021/12/09/13/51/Coronary-Revascularization-the-Focus-of-New-ACC-AHA-Clinical-Guideline-gl-revasc. Published Dec. 9, 2021. Accessed Dec. 9, 2021.
Perspective
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Rajiv Gulati, MD, PhD
The writing committee, reviewers and multisocietal staff deserve huge credit. This was an immense effort, given how many years it has been since the last set of guidelines and the number of studies published in that period.
In my mind, a primary practice-changing provision is the emphasis on a “radial first” vascular access approach in patients undergoing PCI, a class IA recommendation. In meta-analyses of randomized controlled trials comparing radial and femoral access, use of a radial approach reduces mortality in PCI for ACS and reduces bleeding and vascular complications in PCI for stable ischemic heart disease. While adoption of a radial-first approach in the U.S. has been impressive, there remain a considerable number of operators who have yet to transition from a femoral-always approach. The strength of recommendation may persuade some to reconsider.
Another practice-changing highlight is the recommendation for staged complete revascularization in STEMI, based on the findings of reduction in the composite of death and MI in the large COMPLETE randomized trial.
A remaining knowledge gap is in the area of use of left ventricular assist devices in different revascularization settings such cardiogenic shock and high-risk PCI. This is an area where clinical practice is so diverse, reflecting differences in perception and perhaps in local experience. Hopefully randomized controlled trials will address this important knowledge gap and will be reflected in future guideline iterations.
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