What are the guidelines for revascularization in patients with coronary artery disease, according to the American Heart Association (AHA) and American College of Cardiology (ACC)?

From the Guidelines

The American Heart Association (AHA) and American College of Cardiology (ACC) guidelines for coronary artery disease revascularization emphasize a heart team approach, considering patient-specific factors, to determine the optimal strategy, with revascularization indicated for patients with significant left main disease, three-vessel disease, or two-vessel disease involving the proximal left anterior descending artery, particularly in those with reduced left ventricular function, as recommended in the 2024 ESC guidelines 1. The guidelines prioritize a patient-centered approach, incorporating patient preferences and goals, and including shared decision-making, as highlighted in the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1. Key considerations include:

• 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, as noted in the 2021 ACC/AHA/SCAI guideline 1.
• Radial artery access is recommended in patients undergoing percutaneous intervention who have acute coronary syndromes or stable ischemic heart disease, to reduce bleeding and vascular complications compared with a femoral approach, as stated in the 2021 ACC/AHA/SCAI guideline 1.
• 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, as suggested in the 2021 ACC/AHA/SCAI guideline 1.
• Revascularization decisions in patients with diabetes and multivessel CAD are optimized by the use of a Heart Team approach, with surgical revascularization generally favored for patients with diabetes and multivessel disease, complex coronary anatomy, or left main disease, as recommended in the 2024 ESC guidelines 1. The 2024 ESC guidelines provide updated recommendations for revascularization in patients with chronic coronary syndrome, including the use of a Heart Team approach, assessment of procedural risks and post-procedural outcomes, and calculation of the STS score to estimate in-hospital morbidity and 30-day mortality after CABG 1. Overall, the guidelines emphasize the importance of a multidisciplinary approach, patient-centered care, and evidence-based decision-making to optimize outcomes for patients with coronary artery disease, as highlighted in the 2021 ACC/AHA/SCAI guideline 1 and the 2024 ESC guidelines 1.

From the Research

Guidelines for Revascularization

The American Heart Association (AHA) and American College of Cardiology (ACC) provide guidelines for revascularization in patients with coronary artery disease. The guidelines recommend:

• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor for at least 12 months for patients with acute coronary syndrome (ACS) 2
• The choice of P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) should be based on patient characteristics, including the risk of bleeding and myocardial ischemia 2
• For patients with a high risk of bleeding, a shorter duration of DAPT (3-6 months) may be considered 2

Revascularization Strategies

Different revascularization strategies are available, including:

• Percutaneous coronary intervention (PCI) with stent placement
• Coronary artery bypass graft (CABG) surgery
• The choice of revascularization strategy depends on the patient's individual characteristics, including the extent of coronary artery disease and the presence of comorbidities 3

Dual Antiplatelet Therapy

DAPT is a crucial component of medical therapy after PCI. The guidelines recommend:

• Aspirin should be continued indefinitely, with a low dose (75-100 mg daily) preferred over higher doses 4
• A P2Y12 inhibitor should be administered for 12 months after PCI, unless the patient is at high risk for bleeding 4
• Potent P2Y12 inhibitors (prasugrel and ticagrelor) may be more effective than clopidogrel in reducing mortality and major adverse cardiovascular events (MACE) in patients with acute myocardial infarction (AMI) undergoing PCI 5

De-escalation of Dual Antiplatelet Therapy

De-escalation of DAPT may be considered in patients with a high risk of bleeding. The guidelines recommend:

• DAPT de-escalation may reduce the risk of bleeding events compared with continued DAPT with a potent P2Y12 inhibitor 6
• However, the optimal duration of DAPT de-escalation is not well established, and further studies are needed to determine the best approach 6

Patient Characteristics

Patient characteristics, including age, comorbidities, and bleeding risk, play a crucial role in determining the optimal revascularization strategy and DAPT regimen. For example:

• Patients with diabetes may benefit from potent P2Y12 inhibitors 5
• Patients at high risk for bleeding may require a shorter duration of DAPT or a different P2Y12 inhibitor 2
• Older patients (aged 75-79 or >80 years) may still benefit from potent P2Y12 inhibitors, despite a higher risk of bleeding 5