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Key Points
➤ Treatment decisions with regard to coronary revascularization in
patients with coronary artery disease should be based on clinical
indications, regardless of sex, race, or ethnicity, because there is no
evidence that some patients benefit less than others, and efforts to
reduce disparities of care are warranted.
➤ In patients being considered for coronary revascularization for whom
the optimal treatment strategy is unclear, a multidisciplinary Heart
Team approach is recommended. Treatment decisions should be
patient centered, incorporate patient preferences and goals, and
include shared decision-making.
➤ For patients with significant left main disease, surgical
revascularization is indicated to improve survival relative to that likely
to be achieved with medical therapy. Percutaneous revascularization
is a reasonable option to improve survival, compared with medical
therapy, in selected patients with low to medium anatomic complexity
of coronary artery disease and left main disease that is equally
suitable for surgical or percutaneous revascularization.
➤ 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.
Revascularization decisions are based on consideration of disease
complexity, technical feasibility of treatment, and a Heart Team
discussion.
➤ The use of a radial artery as a surgical revascularization conduit
is preferred to 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. Benefits include superior
patency, reduced adverse cardiac events, and improved survival.
➤ 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. Patients with acute
coronary syndromes also benefit from a reduction in mortality rate
with this approach.
➤ 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.