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

Abstract

Aim: The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. Methods: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present 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.

Applying Principles of Regenerative Medicine to Vascular Stent Development

“…Additionally, restenosis and/or other disease progression, after 4 years of stenting, were found in 26–35% patients in a study ( Taniwaki et al, 2014 ; Cassese et al, 2015 ). In patients with peripheral artery stents, 18–40% at 12 months were reported to have in-stent restenosis ( Schillinger et al, 2006 ; Laird et al, 2010 ), while 5–10% for patients with coronary stents ( Shlofmitz et al, 2019 ; Lawton et al, 2021 ). To strategize for improved stent performances, there is a re-surging interest in resorbable biomaterials, surface and biomolecule engineering approaches, capitalizing on the concept of vascular healing and regeneration.…”

Coronary complete revascularization strategy: A puzzle still hard to complete

“…However, this is not enough to recommend a CR strategy “at all cost” for all SIDH patients, and the likely achievement of CR without undue patient risk is one factor that should be considered when choosing the revascularization strategy. Notwithstanding, the most recent, ESC/EACTS and ACC/AHA guidelines point out the evidence gap, leaving an indeterminate recommendation on CR strategy 2,3 …”

2021 ACC/AHA clinical practice guideline on coronary artery revascularisation—‘turf protection’ or ‘misinterpretation of science’?

“…Recent ACC/AHA/SCAI (American College of Cardiology/ American Heart Association/Society of Cardiovascular Angiography and Interventions) Guideline on Myocardial Revascularisation [1] has stirred the aphoristic 'hornets' nest'. Ideally, guidelines should be evidence based consensus documents, advising and informing practicing physicians on how to approach a clinical scenario.…”

“…In PCI ineligible or failed patients, CABG can also be justifiably used to improve outcomes, if there is a large area of myocardium in jeopardy (class 2a). A practical caveat-do not perform CABG after failed primary PCI if there is no-reflow state, poor targets, or absence of ischaemia (class 3: harm) [1]. For patients having undergone primary PCI for a STEMI, CABG has been accorded a class 2a indication, with a rather low level of evidence ['C-EO' (Expert Opinion)], for revascularisation for multivessel coronary artery disease (CAD), in a staged strategy.…”

“…However, 'No RCT (randomised controlled trial) has examined the benefit of adding CABG at the time of emergent cardiac surgery for treatment of a mechanical complication of STEMI versus emergent surgery for the treatment of a mechanical complication alone. In addition, no RCT has examined the benefit of emergent cardiac surgery for the treatment of a mechanical complication of STEMI versus initial medical stabilization and delayed surgery' [1].…”