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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY © 2022 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION AND THE AMERICAN HEART ASSOCIATION, INC. PUBLISHED BY ELSEVIER VOL. 79, NO. 2, 2022 CLINICAL PRACTICE GUIDELINE: FULL TEXT 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 Writing Committee Members* Jennifer S. Lawton, MD, FAHA, Chair† Jacqueline E. Tamis-Holland, MD, FAHA, FACC, FSCAI, Vice Chair‡ Sripal Bangalore, MD, MHA, FACC, FAHA, FSCAI† Eric R. Bates, MD, FACC, FAHA† Theresa M. Beckie, PhD, FAHA† James M. Bischoff, MEd† John A. Bittl, MD, FACC† Mauricio G. Cohen, MD, FACC, FSCAI§ J. Michael DiMaio, MD† Creighton W. Don, MD, PhD, FACC|| Stephen E. Fremes, MD, FACC Mario F. Gaudino, MD, PhD, MSCE, FACC, FAHA† Zachary D. Goldberger, MD, FACC, FAHA‡ Michael C. Grant, MD, MSE† Jang B. Jaswal, MS† Paul A. Kurlansky, MD, FACC† Roxana Mehran, MD, FACC† Thomas S. Metkus Jr, MD, FACC† Lorraine C. Nnacheta, DrPH, MPH† Sunil V. Rao, MD, FACC† Frank W. Sellke, MD, FACC, FAHA† Garima Sharma, MD, FACC† Celina M. Yong, MD, MBA, MSc, FSCAI, FACC, FAHA† Brittany A. Zwischenberger, MD† *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. §ACC/AHA Task Force on Data Standards Representative. ||SCAI Representative. This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, the American College of Cardiology Science and Quality Committee, the American Heart Association Executive Committee, and the Society for Cardiovascular Angiography and Interventions Executive Committee in August 2021. The American College of Cardiology requests that this document be cited as follows: Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 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. J Am Coll Cardiol. 2022;79:e21-e129. This article has been copublished in Circulation. Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.heart.org). For copies of this document, please contact the Elsevier Inc. Reprint Department via fax (212-633-3820) or e-mail (reprints@elsevier.com). Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier website (https://www.elsevier.com/about/policies/copyright/permissions). ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2021.09.006 e22 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 ACC/AHA Joint Patrick T. O'Gara, MD, MACC, FAHA, Chair Committee Joshua A. Beckman, MD, MS, FAHA, FACC, Members Chair-Elect Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair Sana M. Al-Khatib, MD, MHS, FACC, FAHA Anastasia L. Armbruster, PharmD, FACC Kim K. Birtcher, PharmD, MS, AACC Joaquin E. Cigarroa, MD, FACC Lisa de las Fuentes, MD, MS, FAHA Anita Deswal, MD, MPH, FACC, FAHA Dave L. Dixon, PharmD, FACC Lee A. Fleisher, MD, FACC, FAHA Federico Gentile, MD, FACC Zachary D. Goldberger, MD, FACC, FAHA Bulent Gorenek, MD, FACC Norrisa Haynes, MD, MPH Adrian F. Hernandez, MD, MHS Mark A. Hlatky, MD, FACC, FAHA José A. Joglar, MD, FACC, FAHA W. Schuyler Jones, MD, FACC Joseph E. Marine, MD, FACC Daniel B. Mark, MD, MPH, FACC, FAHA Debabrata Mukherjee, MD, FACC, FAHA, FSCAI Latha P. Palaniappan, MD, MS, FACC, FAHA Mariann R. Piano, RN, PhD, FAHA Tanveer Rab, MD, FACC Erica S. Spatz, MD, MS, FACC Jacqueline E. Tamis-Holland, MD, FAHA, FACC, FSCAI Duminda N. Wijeysundera, MD, PhD¶ Y. Joseph Woo, MD, FACC, FAHA Former Joint Committee member; current member during the writing effort. 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. CONTENTS ABSTRACT e22 TOP 10 TAKE-HOME MESSAGES e24 PREAMBLE e25 1. INTRODUCTION e26 1.1. Methodology and Evidence Review ..... e26 1.2. Organization of the Writing Committee ..... e26 1.3. Document Review and Approval ..... e28 1.4. Scope of the Guideline e29 1.5. Class of Recommendation and Level of Evidence e29 1.6. Abbreviations e29 2. IMPROVING EQUITY OF CARE IN REVASCULARIZATION AND SHARED DECISION-MAKING e30 2.1. Improving Equity of Care in Revascularization . e30 2.2. Shared Decision-Making and Informed Consent e31 JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline e23 3. PREPROCEDURAL ASSESSMENT AND THE HEART TEAM....e33 3.1. The Heart Team e33 3.2. Predicting Patient Risk of Death With CABG ... e35 4. DEFINING LESION SEVERITY e35 4.1. Angiography to Define Anatomy and Assess Lesion Severity e35 4.2. Defining Coronary Artery Lesion Complexity: Calculation of the SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) Score e36 4.3. Use of Coronary Physiology to Guide Revascularization With PCI e37 4.4. Intravascular Ultrasound to Assess Lesion Severity e38 5. REVASCULARIZATION IN STEMI e38 5.1. Revascularization of the Infarct Artery in Patients With STEMI e38 5.2. Revascularization of the Non-Infarct Artery in Patients With STEMI e41 6. REVASCULARIZATION IN NSTE-ACS e44 6.1. Coronary Angiography and Revascularization in Patients With NSTE-ACS e44 7. REVASCULARIZATION IN SIHD e47 7.1. Revascularization to Improve Survival in SIHD Compared With Medical Therapy e47 7.2. Revascularization to Reduce Cardiovascular Events in SIHD Compared With Medical Therapy e50 7.3. Revascularization to Improve Symptoms e51 8. SITUATIONS IN WHICH PCI OR CABG WOULD BE PREFERRED e51 8.1. Patients With Complex Disease e51 8.2. Patients With Diabetes e52 8.3. Patients With Previous CABG e53 8.4. DAPT Adherence e54 9. SPECIAL POPULATIONS AND SITUATIONS e55 9.1. Revascularization in Pregnant Patients e55 9.2. Revascularization in Older Patients e55 9.3. Revascularization in Patients With Chronic Kidney Disease (CKD) e56 9.4. Revascularization in Patients Before Noncardiac Surgery e57 9.5. Revascularization in Patients to Reduce Ventricular Arrhythmias e58 9.6. Revascularization in Patients With SCAD ..... e59 9.7. Revascularization in Patients With Cardiac Allografts e59 9.8. Revascularization in Patients Before Transcatheter Aortic Valve Replacement (TAVR) e60 9.9. Revascularization in Patients With Anomalous Coronary Artery e60 10. GENERAL PROCEDURAL ISSUES FOR PCI e60 10.1. Radial and Femoral Approaches for PCI ..... e60 10.2. Choice of Stent Type e61 10.3. Use of Intravascular Imaging e62 10.4. Thrombectomy e63 10.5. Treatment of Calcified Lesions e63 10.6. Treatment of Saphenous Vein Graft (SVG) Disease (Previous CABG) e64 10.7. Treatment of CTO e65 10.8. Treatment of Patients With Stent Restenosis . e66 10.9. Hemodynamic Support for Complex PCI ..... e67 11. PHARMACOTHERAPY IN PATIENTS UNDERGOING PCI e67 11.1. Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI e67 11.2. Intravenous P2Y12 Inhibitors in Patients Undergoing PCI e70 11.3. Intravenous Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing PCI e70 11.4. Heparin, Low-Molecular-Weight Heparin, and Bivalirudin in Patients Undergoing PCI ..... e71 12. GENERAL PROCEDURAL ISSUES FOR CABG e73 12.1. Perioperative Considerations in Patients Undergoing CABG e73 12.2. Bypass Conduits in Patients Undergoing CABG e74 12.3. CABG in Patients Undergoing Other Cardiac Surgery e75 12.4. Use of Epiaortic Ultrasound in Patients Undergoing CABG e76 12.5. Use of Cardiopulmonary Bypass in Patients Undergoing CABG e77 13. PHARMACOTHERAPY IN PATIENTS UNDERGOING CABG e77 13.1. Insulin Infusion and Other Measures to Reduce Sternal Wound Infection in Patients Undergoing CABG e77 e24 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 13.2. Antiplatelet Therapy in Patients Undergoing CABG e79 13.3. Beta Blockers and Amiodarone in Patients Undergoing CABG e80 14. PHARMACOTHERAPY IN PATIENTS AFTER REVASCULARIZATION e81 14.1. Pharmacotherapy for Risk Factor Control in Patients After Revascularization e81 14.2. Dual Antiplatelet Therapy in Patients After PCI . e81 14.3. Antiplatelet Therapy in Patients After CABG . e83 14.4. Beta Blockers in Patients After Revascularization e84 14.5. Beta Blockers for the Prevention of Atrial Fibrillation After CABG e84 14.6. Antiplatelet Therapy in Patients With Atrial Fibrillation on Anticoagulation After PCI e85 15. RECOMMENDATIONS FOR ADDRESSING PSYCHOSOCIAL FACTORS AND LIFESTYLE CHANGES AFTER REVASCULARIZATION ..... e86 15.1. Cardiac Rehabilitation and Education ..... e86 15.2. Smoking Cessation in Patients After Revascularization e87 15.3. Psychological Interventions in Patients After Revascularization e88 16. REVASCULARIZATION OUTCOMES e89 16.1. Assessment of Outcomes in Patients After Revascularization e89 17. UNANSWERED QUESTIONS AND FUTURE DIRECTIONS e90 17.1. Special Populations e90 17.1.1. Underrepresented Racial and Ethnic Groups e90 17.2. Special Clinical Situations e90 17.2.1. Left Ventricular Dysfunction e90 17.2.2. SCAD e91 17.2.3. Coronary Artery Aneurysm e91 17.2.4. Myocardial Bridging e91 17.2.5. Treatment of Graft Failure e91 17.2.6. Antiplatelet Therapy in Patients With ACS After CABG With an Indication for Anticoagulation e91 17.3. Revascularization Considerations e91 17.3.1. Use of the Radial Artery for a Conduit After Radial Artery Catheterization ..... e91 17.3.2. Completeness of Revascularization in Multivessel Disease e92 17.3.3. Hybrid Coronary Surgery e92 17.3.4. Revascularization Before Percutaneous Valve Procedures e92 17.3.5. Revascularization Before Organ Transplantation e93 REFERENCES e94 APPENDIX 1 Author Relationships With Industry and Other Entities (Relevant) e124 APPENDIX 2 Reviewer Relationships With Industry and Other Entities (Comprehensive) e126 TOP 10 TAKE-HOME MESSAGES 1. Treatment decisions regarding 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. 2. 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. 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. 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. 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. Revascularization decisions are based on consideration of disease complexity, technical feasibility of treatment, and a Heart Team discussion. 5. The use of a radial artery as a surgical revascularization conduit is preferred versus the use of a JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline e25 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. 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. Patients with acute coronary syndrome also benefit from a reduction in mortality rate with this 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. 8. Staged percutaneous intervention (while in hospital or after discharge) of a significantly stenosed non-culprit artery in patients presenting with an ST-segment-elevation myocardial infarction is recommended in select patients to improve outcomes. Percutaneous intervention of the nonculprit artery at the time of primary percutaneous coronary intervention is less clear and may be considered in stable patients with uncomplicated revascularization of the culprit artery, low-complexity nonculprit artery disease, and normal renal function. In contrast, percutaneous intervention of the non-culprit artery can be harmful in patients in cardiogenic shock. 9. Revascularization decisions in patients with diabetes and multivessel coronary artery disease are optimized by the use of a Heart Team approach. Patients with diabetes who have triple-vessel disease should undergo surgical revascularization; percutaneous coronary intervention may be considered if they are poor candidates for surgery. 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 because of the interobserver variability in its calculation and its absence of clinical variables. PREAMBLE Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cardiovascular care. The ACC and AHA sponsor the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA. For some guidelines, the ACC and AHA partner with other organizations. Intended Use Clinical practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease (CVD). The focus is on medical practice in the United States, but these guidelines are relevant to patients throughout the world. Although guidelines may be used to inform regulatory or payer decisions, the intent is to improve quality of care and align with patients' interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment. Clinical Implementation Management, in accordance with guideline recommendations, is effective only when followed by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision-making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities. Methodology and Modernization The ACC/AHA Joint Committee on Clinical Practice Guidelines (Joint Committee) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations, including the Institute of Medicine (1,2), and on the basis of internal reevaluation. Similarly, presentation and delivery of guidelines are reevaluated and modified in response to evolving technologies and other factors to optimally facilitate dissemination of information to health care professionals at the point of care. Numerous modifications to the guidelines have been implemented to make them shorter and enhance “user-friendliness.” Guidelines are written and presented in a modular, “knowledge chunk” format, in which each chunk includes a table of recommendations, a brief synopsis, recommendation-specific supportive text and, when appropriate, flow diagrams or additional tables. Hyperlinked references are provided for each modular knowledge chunk to facilitate quick access and review. In recognition of the importance of cost-value considerations, in certain guidelines, when appropriate and feasible, an analysis of value for a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology (3). e26 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 To ensure that guideline recommendations remain current, new data will be reviewed on an ongoing basis by the writing committee and staff. Going forward, targeted sections or knowledge chunks will be revised dynamically after publication and timely peer review of potentially practice-changing science. The previous designations of “full revision” and “focused update” will be phased out. For additional information and policies on guideline development, readers may consult the ACC/AHA guideline methodology manual (4) and other methodology articles (5-7). Selection of Writing Committee Members The Joint Committee strives to ensure that the guideline writing committee contains requisite content expertise and is representative of the broader cardiovascular community by selection of experts across a spectrum of backgrounds, representing different geographic regions, sexes, races, ethnicities, intellectual perspectives/biases, and clinical practice settings. Organizations and professional societies with related interests and expertise are invited to participate as partners or collaborators. Relationships With Industry and Other Entities The ACC and AHA have rigorous policies and methods to ensure that documents are developed without bias or improper influence. The complete policy on relationships with industry and other entities (RWI) can be found online. Appendix 1 of the guideline lists writing committee members' relevant RWI; for the purposes of full transparency, their comprehensive disclosure information is available in a Supplemental Appendix. Comprehensive disclosure information for the Joint Committee is also available online. Evidence Review and Evidence Review Committees In developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data (4,5). Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only key references are cited. An independent evidence review committee is commissioned when there are \( \geq \) 1 questions deemed of utmost clinical importance and merit formal systematic review to determine which patients are most likely to benefit from a drug, device, or treatment strategy, and to what degree. Criteria for commissioning an evidence review committee and formal systematic review include absence of a current authoritative systematic review, feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, relevance to a substantial number of patients, and likelihood that the findings can be translated into actionable recommendations. Evidence review committee members may include methodologists, epidemiologists, clinicians, and biostatisticians. Recommendations developed by the writing committee on the basis of the systematic review are marked “SR”. Guideline-Directed Management and Therapy The term guideline-directed medical therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and both pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm dosage with product insert material and evaluate for contraindications and interactions. Recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States. Patrick T. O'Gara, MD, MACC, FAHA Chair, ACC/AHA Joint Committee on Clinical Practice Guidelines 1. INTRODUCTION 1.1. Methodology and Evidence Review The recommendations listed in this guideline are, whenever possible, evidence based. An initial extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in the U.S. National Library of Medicine and the National Center for Biotechnology information (through PubMed), EMBASE, the Cochrane Collaboration, CINHL Complete, and other selected databases relevant to this guideline, was conducted from May 2019 to September 2019. Key search words included but were not limited to the following: percutaneous coronary intervention, angioplasty, coronary artery bypass graft (CABG) surgery, myocardial infarction, cardiac surgery, stent(s), angiogram, angiography, percutaneous transluminal coronary angioplasty, coronary atherosclerosis, saphenous vein graft, internal mammary artery (IMA) graft, internal thoracic artery graft, arterial graft, post-bypass, non-ST elevated myocardial infarction, vein graft lesions, myocardial revascularization, multivessel PCI, and left ventricular dysfunction. Additional relevant studies, published through May 2021 during the guideline writing process, were also considered by the writing committee and added to the evidence tables when appropriate. The final evidence tables are included in the Online Data Supplement and summarize the evidence used by the writing committee to formulate recommendations. References selected and published in the present document are representative and not all-inclusive. 1.2. Organization of the Writing Committee The writing committee consisted of clinicians, general cardiologists, interventional cardiologists, cardiac surgeons, a cardiac anesthesiologist, an advanced nurse JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline e27 TABLE 1 Associated Guidelines and Statements <table><tr><td>Title</td><td>Organization</td><td>Publication Year (Reference)</td></tr><tr><td colspan="3">Guidelines</td></tr><tr><td>2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death</td><td>AHA/ACC/HRS</td><td>2017 (7)</td></tr><tr><td>2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease</td><td>ACC/AHA</td><td>2020 (8)</td></tr><tr><td>2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease</td><td>ACC/AHA</td><td>2019 (9)</td></tr><tr><td>2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery</td><td>AHA/ACC/AHR/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA</td><td>2019 (11)2019 (12)2014 (13)2019 (14)2014 (15)2016 (3)</td></tr><tr><td>2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline for Blood Cholesterol</td><td>AHA/ACC/AHR/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA/CA</td><td>2019 (11)2019 (12)2014 (13)2019 (14)2014 (15)2016 (3)</td></tr><tr><td>2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease</td><td>AHA/ACC/HRS</td><td>2019 (12)</td></tr><tr><td>2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation</td><td>AHA/ACC/HRS</td><td>2014 (13)</td></tr><tr><td>Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation</td><td>AHA/ACC/HRS</td><td>2019 (14)</td></tr><tr><td>ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease</td><td>ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS</td><td>2014 (15)</td></tr><tr><td>ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction</td><td>ACC/AHA</td><td>2016 (3)</td></tr><tr><td>■ Levine et al., 2016 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction, is now replaced and retired by the present 2021 guideline.</td><td></td><td></td></tr><tr><td>2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes</td><td>AHA/ACC</td><td>2014 (6)</td></tr><tr><td>2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines</td><td>ACCF/AHA</td><td>2013 (5)</td></tr><tr><td>2013 ACCF/AHA Guideline for the Management of Heart Failure</td><td>ACCF/AHA</td><td>2013 (16)</td></tr><tr><td>2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure</td><td>ACC/AHA/HFSA</td><td>2017 (17)</td></tr><tr><td>2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery</td><td>ACCF/AHA</td><td>2011(1)</td></tr><tr><td>■ Hillis et al., 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, is now replaced and retired by the present 2021 guideline.</td><td></td><td></td></tr><tr><td>2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention</td><td>ACCF/AHA/SCAI</td><td>2013 (2)</td></tr><tr><td>■ Levine et al., 2013 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, is now replaced and retired by the present 2021 guideline.</td><td></td><td></td></tr><tr><td>2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death</td><td>AHA/ACC/HRS</td><td>2018 (7)</td></tr><tr><td>2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults</td><td>ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA</td><td>2018 (18)</td></tr><tr><td>2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease</td><td>ACCF/AHA/ACP/AATS/PCNA/SCAI/STS</td><td>2012 (4)</td></tr></table> Statements <table><tr><td>2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment</td><td>ACC</td><td>2018 (19)</td></tr><tr><td>Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff: A Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update: A U.S. Public Health Service Report</td><td>U.S. Public Health Service report</td><td>2008 (20)</td></tr><tr><td>AATS Expert Consensus Review on Prevention and Management of Sternal Wound Infections</td><td>AATS</td><td>2016 (21)</td></tr><tr><td>2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation</td><td>ACC/AHA</td><td>2018 (22)</td></tr><tr><td>Spontaneous Coronary Artery Dissection: Current State of the Science</td><td>AHA</td><td>2018 (23)</td></tr><tr><td>Contemporary Management of Cardiogenic Shock</td><td>AHA</td><td>2017 (24)</td></tr><tr><td>Secondary Prevention After Coronary Artery Bypass Graft Surgery: A Scientific Statement From the American Heart Association</td><td>AHA</td><td>2015 (25)</td></tr><tr><td>Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018</td><td>ADA</td><td>2018 (26)</td></tr></table> AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Association of Physician Assistants; AATS, American Association for Thoracic Surgery; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; ACP, American College of Physicians; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Public Health Association; ASE, American Society of Echocardiography; ASH, American Society of Hypertension; ASNC, American Society of Nuclear Cardiology; ASPC, American Society for Preventive Cardiology; HFSA, Heart Failure Society of America; HRS, Heart Rhythm Society; NLA, National Lipid Association; NMA, National Medical Association; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; SCCT, Society of Cardiovascular Computed Tomography; SCMR, Society for Cardiovascular Magnetic Resonance; and STS, Society of Thoracic Surgeons. e28 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 TABLE 2 Applying ACC/AHA Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)* <table><tr><td colspan="2">CLASS (STRENGTH) OF RECOMMENDATION</td></tr><tr><td>CLASS 1 (STRONG)</td><td>Benefit >>> Risk</td></tr><tr><td colspan="2">Suggested phrases for writing recommendations:Is recommendedIs indicated/useful/effective/beneficialShould be performed/administered/otherComparative-Effectiveness Phrases↑:- Treatment/strategy A is recommended/indicated in preference to treatment B-Treatment A should be chosen over treatment B</td></tr></table> CLASS 2a (MODERATE) Benefit >> Risk Suggested phrases for writing recommendations: <table><tr><td>• Is reasonable</td></tr><tr><td>• Can be useful/effective/beneficial</td></tr><tr><td>• Comparative-Effectiveness Phrases†:</td></tr><tr><td>– Treatment/strategy A is probably recommended/indicated in preference to treatment B</td></tr><tr><td>– It is reasonable to choose treatment A over treatment B</td></tr></table> CLASS 2b (WEAK) Benefit ≥ Risk Suggested phrases for writing recommendations: <table><tr><td>• May/might be reasonable</td></tr><tr><td>• May/might be considered</td></tr><tr><td>• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established</td></tr></table> CLASS 3: No Benefit (MODERATE) Benefit = Risk (Generally, LOE A or B use only) Suggested phrases for writing recommendations: <table><tr><td>• Is not recommended</td></tr><tr><td>• Is not indicated/useful/effective/beneficial</td></tr><tr><td>• Should not be performed/administered/other</td></tr></table> Class 3: Harm (STRONG) Risk > Benefit Suggested phrases for writing recommendations: <table><tr><td>• Potentially harmful</td></tr><tr><td>• Causes harm</td></tr><tr><td>• Associated with excess morbidity/mortality</td></tr><tr><td>• Should not be performed/administered/other</td></tr></table> practitioner, and 2 lay/patient representatives. The writing committee included representatives from the ACC, AHA, Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery, and Society of Thoracic Surgeons (STS). Appendix 1 of the present document lists writing committee members' relevant RWI. For the purposes of full transparency, the writing committee members' comprehensive disclosure information is available in a Supplemental Appendix. LEVEL (QUALITY) OF EVIDENCE‡ LEVEL A • High-quality evidence‡ from more than 1 RCT • Meta-analyses of high-quality RCTs • One or more RCTs corroborated by high-quality registry studies LEVEL B-R (Randomized) • Moderate-quality evidence‡ from 1 or more RCTs • Meta-analyses of moderate-quality RCTs LEVEL B-NR (Nonrandomized) • Moderate-quality evidence‡ from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies • Meta-analyses of such studies LEVEL C-LD (Limited Data) - Randomized or nonrandomized observational or registry studies with limitations of design or execution • Meta-analyses of such studies • Physiological or mechanistic studies in human subjects LEVEL C-EO (Expert Opinion) • Consensus of expert opinion based on clinical experience COR and LOE are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. * The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information). † For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. ‡ The method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial. 1.3. Document Review and Approval This document was reviewed by 2 official reviewers each nominated by the ACC and AHA; 1 reviewer each from the ACC, AHA, STS, American Association for Thoracic Surgery, and SCAI; and 31 individual content reviewers. Reviewers' RWI information was distributed to the writing committee and is published in Appendix 2. The present document was approved for publication by the governing bodies of the ACC, AHA, and SCAI. JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline e29 1.4. Scope of the Guideline The scope of the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” is to provide an update to and to consolidate the 2011 coronary artery bypass graft (CABG) surgery (1) and the 2011 and 2015 percutaneous coronary intervention (PCI) guidelines (2,3), with the added consideration of using a patient-centric disease approach. The applicable sections on revascularization from the 2012 stable ischemic heart disease (SIHD) guideline (4), as well as the 2013 ST-segment-elevation myocardial infarction (STEMI) (5) and 2014 non-ST-segment-elevation myocardial infarction (NSTEMI) guidelines (6), will also be updated. This present guideline will affect the following documents: 1. Replace/retire the 2011 PCI guideline (2). 2. Replace/retire the 2011 CABG guideline (1). 3. Replace/retire the 2015 update in PCI in STEMI guideline (3). 4. Replace/retire the 2013 STEMI guideline, Sections 4.1, 4.2, 4.3, 4.4, 5.3 (deals with transfer after lytic with intent to do PCI), 6.2, 6.4, 7.1, and 7.2 (5). 5. Replace/retire 2014 non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) guideline, Sections 4.4.4, 5.1.1, 5.1.2.1, 5.1.2.2, 5.1.2.3, and 5.2 (6). 6. Replace/retire the 2012 SIHD guideline, Section 5 (4). The intended primary target audience consists of cardiovascular clinicians who are involved in the care of patients for whom revascularization is considered or indicated. Coronary artery disease (CAD) is to be approached with the most current treatment options and treated as a “condition.” Recommendations are stated in reference to the patients and their condition. The focus is to provide the most up-to-date evidence to inform the clinician during shared decision-making with the patient. Although the document is not intended to be a procedural-based manual of recommendations that outlines the best practice for coronary revascularization, there are certain techniques that surgeons or interventional cardiologists might use that are associated with improved clinical outcomes. In developing the 2021 coronary artery revascularization guideline, the writing committee reviewed previously published guidelines and related statements. Table 1 contains a list of these publications and statements deemed pertinent to this writing effort and is intended for use as a resource, thus obviating the need to repeat existing guideline recommendations. 1.5. Class of Recommendation and Level of Evidence The Class of Recommendation (COR) indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 2) (1). 1.6. Abbreviations <table><tr><td>Abbreviation</td><td>Meaning/Phrase</td></tr><tr><td>ACS</td><td>acute coronary syndrome</td></tr><tr><td>AKI</td><td>acute kidney injury</td></tr><tr><td>AMI</td><td>acute myocardial infarction</td></tr><tr><td>AVR</td><td>aortic valve replacement</td></tr><tr><td>BIMA</td><td>bilateral internal mammary artery</td></tr><tr><td>BMS</td><td>bare-metal stent</td></tr><tr><td>CABG</td><td>coronary artery bypass graft</td></tr><tr><td>CAD</td><td>coronary artery disease</td></tr><tr><td>CKD</td><td>chronic kidney disease</td></tr><tr><td>COR</td><td>Class of Recommendation</td></tr><tr><td>CTO</td><td>chronic total occlusion</td></tr><tr><td>CVD</td><td>cardiovascular disease</td></tr><tr><td>DAPT</td><td>dual antiplatelet therapy</td></tr><tr><td>DES</td><td>drug-eluting stent</td></tr><tr><td>ECG</td><td>electrocardiogram</td></tr><tr><td>FFR</td><td>fractional flow reserve</td></tr><tr><td>GDMT</td><td>guideline-directed medical therapy</td></tr><tr><td>iFR</td><td>instantaneous wave-free ratio</td></tr><tr><td>IMA</td><td>internal mammary artery</td></tr><tr><td>ISR</td><td>in-stent restenosis</td></tr><tr><td>IVUS</td><td>intravascular ultrasound</td></tr><tr><td>LAD</td><td>left anterior descending</td></tr><tr><td>LIMA</td><td>left internal mammary artery</td></tr><tr><td>LOE</td><td>Level of Evidence</td></tr><tr><td>MACE</td><td>major adverse cardiovascular events</td></tr><tr><td>MI</td><td>myocardial infarction</td></tr><tr><td>NSTE-ACS</td><td>non-ST-segment-elevation acute coronary syndrome</td></tr><tr><td>NSTEMI</td><td>non-ST-segment-elevation myocardial infarction</td></tr><tr><td>OCT</td><td>optical coherence tomography</td></tr><tr><td>PCI</td><td>percutaneous coronary intervention</td></tr><tr><td>RCT</td><td>randomized controlled trial</td></tr><tr><td>SCAD</td><td>spontaneous coronary artery dissection</td></tr><tr><td>SIHD</td><td>stable ischemic heart disease</td></tr><tr><td>STEMI</td><td>ST-segment-elevation myocardial infarction</td></tr><tr><td>SVG</td><td>saphenous vein graft</td></tr><tr><td>SYNTAX</td><td>Synergy Between PCI With TAXUS and Cardiac Surgery</td></tr><tr><td>TAVR</td><td>transcatheter aortic valve replacement</td></tr><tr><td>UFH</td><td>unfractionated heparin</td></tr><tr><td>VT</td><td>ventricular tachycardia</td></tr></table> e30 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 2. IMPROVING EQUITY OF CARE IN REVASCULARIZATION AND SHARED DECISION-MAKING 2.1. Improving Equity of Care in Revascularization Recommendation to Improve Equity of Care in Revascularization Referenced studies that support the recommendation are summarized in Online Data Supplement 1. <table><tr><td>COR</td><td>LOE</td><td>RECOMMENDATION</td></tr><tr><td>1</td><td>B-NR</td><td>1. In patients who require coronary revascularization, treatment decisions should be based on clinical indication, regardless of sex (1-7) or race or ethnicity (8-10), and efforts to reduce disparities of care are warranted (11,12).</td></tr></table> Synopsis Health disparities by sex and race are evident across the spectrum of CVD in the United States (7,9,13-15), and mounting evidence demonstrates that social factors are strongly associated with cardiovascular health outcomes (16, 17). Differences in access to care, cardiovascular treatment, mortality rate, and readmission outcomes persist by important sociodemographic characteristics that include but are not limited to socioeconomic status, race, and ethnicity (18-22). African Americans (23-25), Hispanics (24), and South Asians (26) (with substantial heterogeneity within Asian subgroups) have a higher prevalence of cardiovascular risk factors and crude mortality (16). Although access to health care remains a problem, even after entering into the health care system, women and non-White patients are less likely to receive reperfusion therapy, an invasive strategy, or revascularization (9,13,27-37) and more likely to have worse outcomes (37-40). As compared with White male patients, women and Black patients with acute coronary syndrome (ACS) receive less guideline-based therapy in hospital and at discharge (27,32,41,42). Differences in comorbidities, health education, presentation, socioeconomic status, regional hospital capability and quality, and insurance and health care access (15,28,29,35,37,43-48) contribute to the problem, but disparities can persist despite adjustment for these factors (7,30-32,49,50). In a study of patients with cardiac symptoms, clinicians were less likely to recommend cardiac catheterization to women and non-White patients than to White male patients, despite being given the exact same clinical vignette for White male patients (51). Continued vigilance against conscious and unconscious gender, racial, and ethnic discrimination and purposeful efforts to increase the implementation of guideline-based therapy for all patients, regardless of sex, race, or ethnicity, are needed. Recommendation-Specific Supportive Text After controlling for greater baseline comorbidities among patients undergoing revascularization, several observational studies have demonstrated that Black (28,52-54), Hispanic (24,50), and Asian (55,56) patients have outcomes similar to those of White patients. Similarly, after controlling for baseline comorbidities and treatment strategy, most studies demonstrate similar outcomes in women and men (1-6). Post hoc analyses of randomized trials evaluating revascularization provide compelling evidence, inasmuch as enrolled patients are more similar and the decision to revascularize is protocol driven. In the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial, revascularization rates were lowest and mortality rates highest for Hispanics and African Americans, but there was no interaction between race and the mortality benefit of revascularization (9). Similar results have been reported for women with shock in the CULPRIT-SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock trial (57). In the TACTICS-TIMI 18 (Treat Angina With Aggrastat and Determine Cost of Therapy With Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction 18) trial, evaluating patients with NSTE-ACS, non-White patients and female patients had more comorbidity and more major adverse cardiovascular event (MACE) outcomes than White and male patients but were revascularized at the same rate. After adjustment for baseline characteristics, the invasive strategy was equally beneficial for all patients, without evidence of racial differences (10). A meta-analysis of RCT of invasive vs conservative strategies in women and men with NSTE-ACS reported a similar proportional benefit of an invasive strategy in women and men, (although low risk women with biomarker negative ACS did not derive a benefit to an early invasive strategy)(1). Additionally, studies have shown similar relative benefits of primary PCI (3) and revascularization in SIHD (5,6) for women and men. In view of these findings, the decision to offer revascularization should be made on the basis of a patient's clinical characteristics, and preferences and should be the same for all patients, regardless of sex, race, or ethnicity. JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline e31 2.2. Shared Decision-Making and Informed Consent Recommendations for Shared Decision-Making and Informed Consent <table><tr><td></td><td>COR</td><td>LOE</td><td>RECOMMENDATIONS</td></tr><tr><td>1</td><td>C-LD</td><td></td><td>1. In patients undergoing revascularization, decisions should be patient centered—that is, considerate of the patient's preferences and goals, cultural beliefs, health literacy, and social determinants of health—and made in collaboration with the patient's support system (1,2).</td></tr><tr><td>1</td><td>C-LD</td><td></td><td>2. In patients undergoing coronary angiography or revascularization, adequate information about benefits, risks, therapeutic consequences, and potential alternatives in the performance of percutaneous and surgical myocardial revascularization should be given, when feasible, with sufficient time for informed decision-making to improve clinical outcomes (3-5).</td></tr></table> Synopsis Shared decision-making (Figure 1) is a collaborative approach that provides patients with unbiased, evidence-based information on treatment choices and encourages a dialogue between patients and providers, with the aim of making decisions that use scientific evidence and align with the patient's values and preferences (3,4,6). It is essential that the clinician use terminology that the patient understands to allow effective processing of health information and to foster the patient's participation in treatment decisions (7). The use of online modules, decision aids, or videos about treatment options can help patients better understand the risks and benefits of various therapies. Patients are interested in how a recommended treatment might impact their prognosis and quality of life (8). In the treatment decision-making process, the patient's best interest should be placed first, and the active participation of the patient and significant others should be engaged. The contributions of social determinants of health to CVD are poorly understood (9,10) but may impact a patient's decision with regard to treatments. In high-income countries, 4 socioeconomic status metrics have been associated with CVD: income level, educational attainment, employment status, and environmental factors (11-13). Recommendation-Specific Supportive Text 1. Shared decision-making is vital to patient-centered care. Shared decision-making improves patients' understanding of treatment options, increases realistic expectations of benefits and harms, stimulates engagement in decision-making, and improves concordance between patients' values and treatment choices (14-17). Factors complicating effective shared decision-making include low health literacy, adverse social determinants of health, cultural beliefs, language barriers, advanced age, and complex comorbidities. Health literacy is associated with socioeconomic position, English proficiency, and the development of general literacy (18). Incorporating a patient's preferences into the decision-making process improves the patient's well-being through better treatment adherence and higher satisfaction with health outcomes (5,19,20). A patient's right to decline recommended treatments must be respected and should be acknowledged in a written document after the patient has received sufficient information from the Heart Team (8). 2. Patients cannot engage in shared decision-making until they know the potential benefits and risks of all treatment options. Clinicians must provide evidence-based estimates of risks, benefits, and costs of therapeutic options (8,21,22). Procedure-related and long-term risks and benefits, such as survival, quality of life, and the need for late reintervention, should be included in such discussions (Table 3) (8). Patients should also be educated about the need for continued medical therapy with or without revascularization, as well as lifestyle modification and other secondary prevention strategies (21,23). In some situations, in which the optimal treatment strategy is uncertain, it may be appropriate to defer revascularization to allow time for consultation and discussion. The clinician must act in the patient's best interest and convey the risks and benefits of all revascularization treatment options, consult with additional specialists when appropriate, and allow the patient to consult family (24,25). Challenges exist when scientific data support a treatment, but the patient prefers an alternative treatment; in 1 study, patients preferred PCI over CABG, even when the risk of death with PCI was double the risk with CABG (26). e32 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 FIGURE 1 Shared Decision-Making Algorithm TABLE 3 Ideal Components of the Shared Decision-Making and Informed Consent Process <table><tr><td>Patient-Centered Care</td></tr><tr><td>Assess a patient's ability to understand complex health information</td></tr><tr><td>Seek support of family/others</td></tr><tr><td>Elicit and respect cultural, racial, ethnic, or religious preferences and values</td></tr><tr><td>Evaluate social determinants of health (education, income, access to health care)</td></tr><tr><td>Improve telephone/telemedicine access</td></tr><tr><td>Discuss treatment alternatives and how each affects the patient's quality of life</td></tr><tr><td>Shared Decision-Making</td></tr><tr><td>Encourage questions and explain the patient's role in the decision-making partnership</td></tr><tr><td>Clearly and accurately communicate the potential risks and benefits of a particular procedure and alternative treatments</td></tr><tr><td>Ensure that patients have a key role in deciding what revascularization approach is appropriate</td></tr><tr><td>Use shared decision aids:Alphabetical List of Decision Aids by Health Topic, Ottawa Hospital Research Institute (https://decisionaid.ohri.ca/implement.html) (27)SHARE Approach Curriculum Tools, Agency for Health Care Research and Quality (https://www.ahrq.gov/health-literacy/curriculum-tools/shareddecisionmaking/tools/tool-1/index.html) (28)</td></tr><tr><td>Spend sufficient time to engage in shared decision-making; allow for a second opinion</td></tr><tr><td>Work with a chaplain, social worker, or other team members to facilitate shared decision-making</td></tr><tr><td>Encourage patients to share their fears, stress, or other emotions, and address appropriately</td></tr><tr><td>Negotiate decision in partnership with the patient and family members</td></tr><tr><td>Respect patient's autonomy to decline recommended treatment</td></tr></table> Continued in the next column JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline e33 TABLE 3 Continued <table><tr><td>Consent Procedures</td></tr><tr><td>Use plain language, avoiding jargon, and adopt the patient's words; integrate pictures to teach</td></tr><tr><td>Document teach-back of patient's knowledge and understanding</td></tr><tr><td>Conduct conversations with a trained interpreter, as needed</td></tr><tr><td>Provide patient-specific short- and long-term risks, benefits, and alternative treatments</td></tr><tr><td>Provide unbiased, evidence-based, reliable, accessible, and relevant information to patient</td></tr><tr><td>Discuss specific risks and benefits with regard to survival, relief of angina, quality of life, and potential additional intervention, as well as uncertainties associated with different treatment strategies</td></tr><tr><td>Provide patient time to reflect on the trade-offs imposed by the outcome estimates</td></tr><tr><td>Provide information on the level of operator expertise, volume of the facility, and local results in the performance of coronary revascularization options</td></tr><tr><td>Clearly inform of the need for continued medical therapy and lifestyle modifications</td></tr></table> 3. PREPROCEDURAL ASSESSMENT AND THE HEART TEAM 3.1. The Heart Team Recommendation for the Heart Team Referenced studies that support the recommendation are summarized in Online Data Supplement 2. <table><tr><td>COR</td><td>LOE</td><td>RECOMMENDATION</td></tr><tr><td>1</td><td>B-NR</td><td>1. In patients for whom the optimal treatment strategy is unclear, a Heart Team approach that includes representatives from interventional cardiology, cardiac surgery, and clinical cardiology is recommended to improve patient outcomes (1-7).</td></tr></table> Synopsis The multidisciplinary Heart Team, which involves the cardiologist, cardiac surgeon, and other specialists, has become a critical component of the revascularization decision. Initially, the Heart Team approach to decision-making for coronary disease arose within the context of randomized trials comparing PCI with CABG to ensure selected patients were equally suited for either strategy before randomization (8). Subsequently, the Heart Team has become an important paradigm in clinical practice, emphasizing the importance of team consensus on the optimal approach to revascularization. Ideal situations for Heart Team consideration include patients with complex coronary disease, comorbid conditions that could impact the success of the revascularization strategy, and other clinical or social situations that may impact outcomes (Figure 2 and Table 4). The Heart Team process should rest on the principles of collegiality, mutual respect, and commitment to excellence. The logistics of convening the Heart Team should depend on local resources and workflows. Models include daily to weekly scheduled meetings and ad hoc activation (1,2,4,6,9). Remote conferences have also been advocated (9). Additionally, there should be a process for rapid activation of the Heart Team for urgent or emergency clinical situations. Recommendation-Specific Supporting Text 1. Observational studies using the Heart Team have included interventional cardiology, cardiac surgery, and noninvasive cardiologists (1-4,6). Additional professionals who offer input may include the patient's primary physician, as well as palliative care, critical care, anesthesiology, and imaging specialists. Observational studies have demonstrated favorable outcomes when the Heart Team was used in cases of unprotected left main disease, triple-vessel disease, double-vessel disease involving the proximal left anterior descending (LAD) artery, or single-vessel disease involving the proximal LAD artery in the context of diabetes, or in cases in which the referring physician requested such evaluation (5-7,10,11). Heart Team decisions are generally reproducible (4) and associated with good outcomes (2,6). e34 Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline JACC VOL. 79, NO. 2, 2022 JANUARY 18, 2022:e21-e129 FIGURE 2 Phases of Patient-Centric Care in the Treatment of Coronary Artery Disease CV indicates cardiovascular; SIHD, stable ischemic heart disease; and STEMI, ST-segment-elevation myocardial infarction. TABLE 4 Factors for Consideration by the Heart Team <table><tr><td>Coronary Anatomy</td></tr><tr><td>■ Left main disease</td></tr><tr><td>■ Multivessel disease</td></tr><tr><td>■ High anatomic complexity (i.e., bifurcation disease, high SYNTAX score)</td></tr><tr><td>Comorbidities</td></tr><tr><td>■ Diabetes</td></tr><tr><td>■ Systolic dysfunction</td></tr><tr><td>■ Coagulopathy</td></tr><tr><td>■ Valvular heart disease</td></tr><tr><td>■ Frailty</td></tr><tr><td>■ Malignant neoplasm</td></tr><tr><td>■ End-stage renal disease</td></tr><tr><td>■ Chronic obstructive pulmonary disease</td></tr><tr><td>■ Immunosuppression</td></tr><tr><td>■ Debilitating neurological disorders</td></tr><tr><td>■ Liver disease/cirrhosis</td></tr><tr><td>■ Prior CVA</td></tr><tr><td>■ Calcified/porcelain aorta</td></tr><tr><td>■ Aortic aneurysm</td></tr></table> Continued in the next column TABLE 4 Continued <table><tr><td>Procedural Factors</td></tr><tr><td>■ Local and regional outcomes</td></tr><tr><td>■ Access site for PCI</td></tr><tr><td>■ Surgical risk</td></tr><tr><td>■ PCI risk</td></tr><tr><td>Patient Factors</td></tr><tr><td>■ Unstable presentation or shock</td></tr><tr><td>■ Patient preferences</td></tr><tr><td>■ Inability or unwillingness to adhere to DAPT</td></tr><tr><td>■ Patient social support</td></tr><tr><td>■ Religious beliefs</td></tr><tr><td>■ Patient education, knowledge, and understanding</td></tr><tr><td>CVA indicates cerebrovascular accident; DAPT, dual antiplatelet therapy; PCI, percutaneous coronary intervention; and SYNT …(549,019 more chars)