2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

On December 9, the  American Heart Association (AHA) and American College of Cardiology (ACC) jointly released a clinical practice guideline for coronary artery revascularization in patients with coronary artery disease.  The top ten take-home messages are:

1. Treatment decisions regarding coronary revascularization in patients with coronary artery disease should be based on clinical indications, regardless of sex, race, or ethnicity.

2. In patients being considered for coronary revascularization for whom the optimal treatment strategy is unclear, a multidisciplinary Heart Team approach is recommended. 

3. For patients with significant left main disease, surgical revascularization is indicated to improve survival relative to that likely to be achieved with medical therapy. 

4. Updated evidence from contemporary trials supplement older evidence with regard to mortality benefit of revascularization in patients with stable ischemic heart disease, normal left ventricular ejection fraction, and triple-vessel coronary artery disease. Surgical revascularization may be reasonable to improve survival. A survival benefit with percutaneous revascularization is uncertain. 

5. The use of a radial artery as a surgical revascularization conduit is preferred versus the use of a saphenous vein conduit to bypass the second most important target vessel with significant stenosis after the left anterior descending coronary artery. 

6. Radial artery access is recommended in patients undergoing percutaneous intervention who have acute coronary syndrome or stable ischemic heart disease, to reduce bleeding and vascular complications compared with a femoral approach.

7. A short duration of dual antiplatelet therapy after percutaneous revascularization in patients with stable ischemic heart disease is reasonable to reduce the risk of bleeding events. 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 (Previous recommendations called for 6 or 12 months of DAPT)

8. Staged percutaneous intervention (while in hospital or after discharge) of a significantly stenosed nonculprit artery in patients presenting with an ST-segment–elevation myocardial infarction is recommended in select patients to improve outcomes. 

9. Revascularization decisions in patients with diabetes and multivessel coronary artery disease are optimized by the use of a Heart Team approach.  

10. Treatment decisions for patients undergoing surgical revascularization of coronary artery disease should include the calculation of a patient’s surgical risk with the Society of Thoracic Surgeons score. The usefulness of the SYNTAX score calculation in treatment decisions is less clear.