Expert Review| Volume 37, ISSUE 1, P135-148, January 2023

Analysis of the Updated ACC/AHA Coronary Revascularization Guidelines With Implications for Cardiovascular Anesthesiologists and Intensivists

Published:September 27, 2022DOI:
      PHYSICIANS DEDICATED TO the care of patients with cardiovascular disease face a daunting task, given the constant evolution of data and guidelines. The American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) released an updated clinical practice guideline for coronary artery revascularization (CAR) in December 2021 to provide a foundation for decision-making in the care of patients in need.
      • Lawton JS
      • Tamis-Holland JE
      Writing Committee Members
      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.
      This current guideline is nearly all-encompassing on the topics of CAR and related items; per decree of the guideline writing group, the updated guidelines are intended to replace a myriad of several now-outdated guidelines, including the ACC/AHA 2011 guidelines on percutaneous coronary interventions (PCI) and coronary artery bypass grafting (CABG), among others.
      • Lawton JS
      • Tamis-Holland JE
      Writing Committee Members
      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.
      The breadth of the 2021 CAR guidelines is considerable; this manuscript offers a focused review of the major updated guideline components targeted toward cardiothoracic anesthesiologists and intensivists, aiming to provide a summary of the items that are of particular importance to perioperative patient care. These guidelines, it should be noted, are not without controversy; not all stakeholders in CAR have endorsed the guidelines. A concise comment on the objections raised by cardiac surgeons also is included.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lawton JS
        • Tamis-Holland JE
        • Writing Committee Members
        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: e21-129
        • Petrie MC
        • Jhund PS
        • She L
        • et al.
        Ten-year outcomes after coronary artery bypass grafting according to age in patients with heart failure and left ventricular systolic dysfunction: An analysis of the extended follow-up of the STICH Trial (Surgical Treatment for Ischemic Heart Failure).
        Circulation. 2016; 134: 1314-1324
        • Velazquez EJ
        • Lee KL
        • Jones RH
        • et al.
        Coronary-artery bypass surgery in patients with ischemic cardiomyopathy.
        N Engl J Med. 2016; 374: 1511-1520
      1. Coronary artery surgery study (CASS): A randomized trial of coronary artery bypass surgery. Survival data.
        Circulation. 1983; 68: 939-950
        • Yusuf S
        • Zucker D
        • Peduzzi P
        • et al.
        Effect of coronary artery bypass graft surgery on survival: Overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.
        Lancet. 1994; 344: 563-570
      2. Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina.
        N Engl J Med. 1984; 311: 1333-1339
        • Takaro T
        • Peduzzi P
        • Detre KM
        • et al.
        Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease.
        Circulation. 1982; 66: 14-22
        • Bittl JA
        • He Y
        • Jacobs AK
        • et al.
        Bayesian methods affirm the use of percutaneous coronary intervention to improve survival in patients with unprotected left main coronary artery disease.
        Circulation. 2013; 127: 2177-2185
        • Maron DJ
        • Hochman JS
        • Reynolds HR
        • et al.
        Initial invasive or conservative strategy for stable coronary disease.
        N Engl J Med. 2020; 382: 1395-1407
        • Bangalore S
        • Maron DJ
        • Stone GW
        • et al.
        Routine revascularization versus initial medical therapy for stable ischemic heart disease: A systematic review and meta-analysis of randomized trials.
        Circulation. 2020; 142: 841-857
        • Hueb WA
        • Soares PR
        • Almeida De Oliveira S
        • et al.
        Five-year follow-op of the medicine, angioplasty, or surgery study (MASS): A prospective, randomized trial of medical therapy, balloon angioplasty, or bypass surgery for single proximal left anterior descending coronary artery stenosis.
        Circulation. 1999; 100: II107-II113
        • Windecker S
        • Stortecky S
        • Stefanini GG
        • et al.
        Revascularisation versus medical treatment in patients with stable coronary artery disease: Network meta-analysis.
        BMJ. 2014; 348: g3859
        • Cashin WL
        • Sanmarco ME
        • Nessim SA
        • et al.
        Accelerated progression of atherosclerosis in coronary vessels with minimal lesions that are bypassed.
        N Engl J Med. 1984; 311: 824-828
        • Pitt B
        • Waters D
        • Brown WV
        • et al.
        Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators.
        N Engl J Med. 1999; 341: 70-76
        • Laukkanen JA
        • Kunutsor SK.
        Revascularization versus medical therapy for the treatment of stable coronary artery disease: A meta-analysis of contemporary randomized controlled trials.
        Int J Cardiol. 2021; 324: 13-21
        • Spertus JA
        • Jones PG
        • Maron DJ
        • et al.
        Health-status outcomes with invasive or conservative care in coronary disease.
        N Engl J Med. 2020; 382: 1408-1419
        • Abdallah MS
        • Wang K
        • Magnuson EA
        • et al.
        Quality of life after PCI vs CABG among patients with diabetes and multivessel coronary artery disease: A randomized clinical trial.
        JAMA. 2013; 310: 1581-1590
        • Mohr FW
        • Morice MC
        • Kappetein AP
        • et al.
        Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial.
        Lancet. 2013; 381: 629-638
        • Bangalore S
        • Toklu B
        • Patel N
        • et al.
        Newer-generation ultrathin strut drug-eluting stents versus older second-generation thicker strut drug-eluting stents for coronary artery disease.
        Circulation. 2018; 138: 2216-2226
        • Park SJ
        • Ahn JM
        • Kim YH
        • et al.
        Trial of everolimus-eluting stents or bypass surgery for coronary disease.
        N Engl J Med. 2015; 372: 1204-1212
        • Farkouh ME
        • Domanski M
        • Dangas GD
        • et al.
        Long-term survival following multivessel revascularization in patients with diabetes: The FREEDOM Follow-On Study.
        J Am Coll Cardiol. 2019; 73: 629-638
        • Head SJ
        • Milojevic M
        • Daemen J
        • et al.
        Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: A pooled analysis of individual patient data.
        Lancet. 2018; 391: 939-948
        • Brodie BR
        • Garg A
        • Stuckey TD
        • et al.
        Fixed and modifiable correlates of drug-eluting stent thrombosis from a large all-comers registry: Insights from ADAPT-DES.
        Circ Cardiovasc Interv. 2015; 8e002568
        • Cutlip DE
        • Kereiakes DJ
        • Mauri L
        • et al.
        Thrombotic complications associated with early and late nonadherence to dual antiplatelet therapy.
        JACC Cardiovasc Interv. 2015; 8: 404-410
        • Smilowitz NR
        • Gupta N
        • Guo Y
        • et al.
        Acute myocardial infarction during pregnancy and the puerperium in the United States.
        Mayo Clin Proc. 2018; 93: 1404-1414
        • Tweet MS
        • Lewey J
        • Smilowitz NR
        • et al.
        Pregnancy-associated myocardial infarction: Prevalence, causes, and interventional management.
        Circ Cardiovasc Interv. 2020; (CIRCINTERVENTIONS120008687. Online ahead of print)
        • Graham MM
        • Ghali WA
        • Faris PD
        • et al.
        Survival after coronary revascularization in the elderly.
        Circulation. 2002; 105: 2378-2384
        • Madhavan MV
        • Gersh BJ
        • Alexander KP
        • et al.
        Coronary artery disease in patients ≥80 years of age.
        J Am Coll Cardiol. 2018; 71: 2015-2040
        • McFalls EO
        • Ward HB
        • Moritz TE
        • et al.
        Coronary-artery revascularization before elective major vascular surgery.
        N Engl J Med. 2004; 351: 2795-2804
        • Cook JR
        • Rizo-Patron C
        • Curtis AB
        • et al.
        Effect of surgical revascularization in patients with coronary artery disease and ventricular tachycardia or fibrillation in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Registry.
        Am Heart J. 2002; 143: 821-826
        • Hayes SN
        • Kim ESH
        • Saw J
        • et al.
        Spontaneous coronary artery dissection: Current state of the science: A scientific statement from the American Heart Association.
        Circulation. 2018; 137: e523-e557
        • Luc JGY
        • Choi JH
        • Rizvi SA
        • et al.
        Percutaneous coronary intervention versus coronary artery bypass grafting in heart transplant recipients with coronary allograft vasculopathy: A systematic review and meta-analysis of 1,520 patients.
        Ann Cardiothorac Surg. 2018; 7: 19-30
        • Ferrante G
        • Rao SV
        • Juni P
        • et al.
        Radial versus femoral access for coronary interventions across the entire spectrum of patients with coronary artery disease: A meta-analysis of randomized trials.
        JACC Cardiovasc Interv. 2016; 9: 1419-1434
        • Valgimigli M
        • Gagnor A
        • Calabro P
        • et al.
        Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: A randomised multicentre trial.
        Lancet. 2015; 385: 2465-2476
        • Piccolo R
        • Bonaa KH
        • Efthimiou O
        • et al.
        Drug-eluting or bare-metal stents for percutaneous coronary intervention: A systematic review and individual patient data meta-analysis of randomised clinical trials.
        Lancet. 2019; 393: 2503-2510
        • Zhang J
        • Gao X
        • Kan J
        • et al.
        Intravascular ultrasound versus angiography-guided drug-eluting stent implantation: The ULTIMATE Trial.
        J Am Coll Cardiol. 2018; 72: 3126-3137
        • Hong SJ
        • Zhang JJ
        • Mintz GS
        • et al.
        Improved 3-year cardiac survival after IVUS-guided long DES implantation: A patient-level analysis from 2 randomized trials.
        JACC Cardiovasc Interv. 2022; 15: 208-216
        • Gao XF
        • Ge Z
        • Kong XQ
        • et al.
        3-Year outcomes of the ULTIMATE trial comparing intravascular ultrasound versus angiography-guided drug-eluting stent implantation.
        JACC Cardiovasc Interv. 2021; 14: 247-257
        • Jolly SS
        • Cairns JA
        • Yusuf S
        • et al.
        Randomized trial of primary PCI with or without routine manual thrombectomy.
        N Engl J Med. 2015; 372: 1389-1398
        • Abdel-Wahab M
        • Richardt G
        • Joachim Buttner H
        • et al.
        High-speed rotational atherectomy before paclitaxel-eluting stent implantation in complex calcified coronary lesions: The randomized ROTAXUS (Rotational Atherectomy Prior to Taxus Stent Treatment for Complex Native Coronary Artery Disease) trial.
        JACC Cardiovasc Interv. 2013; 6: 10-19
        • Fefer P
        • Knudtson ML
        • Cheema AN
        • et al.
        Current perspectives on coronary chronic total occlusions: The Canadian Multicenter Chronic Total Occlusions Registry.
        J Am Coll Cardiol. 2012; 59: 991-997
        • Lee SW
        • Lee PH
        • Ahn JM
        • et al.
        Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total occlusion.
        Circulation. 2019; 139: 1674-1683
        • Alfonso F
        • Byrne RA
        • Rivero F
        • et al.
        Current treatment of in-stent restenosis.
        J Am Coll Cardiol. 2014; 63: 2659-2673
        • Thiele H
        • Zeymer U
        • Neumann FJ
        • et al.
        Intraaortic balloon support for myocardial infarction with cardiogenic shock.
        N Engl J Med. 2012; 367: 1287-1296
        • O'Neill WW
        • Kleiman NS
        • Moses J
        • et al.
        A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: The PROTECT II Study.
        Circulation. 2012; 126: 1717-1727
      3. Impella-supported PCI in high-risk patients with complex coronary artery disease and reduced left ventricular function (PROTECT IV); 2022. Available at: Accessed September 2, 2022.

        • Nordt SP
        • Clark RF
        • Castillo EM
        • et al.
        Comparison of three aspirin formulations in human volunteers.
        West J Emerg Med. 2011; 12: 381-385
        • Steinhubl SR
        • Berger PB
        • Mann 3rd, JT
        • et al.
        Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: A randomized controlled trial.
        JAMA. 2002; 288: 2411-2420
        • Wiviott SD
        • Antman EM
        • Gibson CM
        • et al.
        Evaluation of prasugrel compared with clopidogrel in patients with acute coronary syndromes: Design and rationale for the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN with prasugrel Thrombolysis In Myocardial Infarction 38 (TRITON-TIMI 38).
        Am Heart J. 2006; 152: 627-635
        • Bhatt DL
        • Stone GW
        • Mahaffey KW
        • et al.
        Effect of platelet inhibition with cangrelor during PCI on ischemic events.
        N Engl J Med. 2013; 368: 1303-1313
        • Fischer K
        • Bodalbhai F
        • Awudi E
        • et al.
        Reversing bleeding associated with antiplatelet use: The role of tranexamic acid.
        Cureus. 2020; 12: e10290
        • Williams JB
        • McConnell G
        • Allender JE
        • et al.
        One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program.
        J Thorac Cardiovasc Surg. 2019; 157: 1881-1888
        • Li M
        • Zhang J
        • Gan TJ
        • et al.
        Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: A randomized clinical trial.
        Eur J Cardiothorac Surg. 2018; 54: 491-497
        • Gaudino M
        • Benedetto U
        • Fremes S
        • et al.
        Association of radial artery graft vs saphenous vein graft with long-term cardiovascular outcomes among patients undergoing coronary artery bypass grafting: A systematic review and meta-analysis.
        JAMA. 2020; 324: 179-187
        • Sabik 3rd, JF
        • Bakaeen FG
        • Ruel M
        • et al.
        The American Association for Thoracic Surgery and The Society of Thoracic Surgeons reasoning for not endorsing the 2021 ACC/AHA/SCAI Coronary Revascularization Guidelines.
        Ann Thorac Surg. 2022; 113: 1065-1068
        • Cameron A
        • Davis KB
        • Green G
        • et al.
        Coronary bypass surgery with internal-thoracic-artery grafts: Effects on survival over a 15-year period.
        N Engl J Med. 1996; 334: 216-219
        • Gaudino M
        • Bakaeen F
        • Benedetto U
        • et al.
        Use rate and outcome in bilateral internal thoracic artery grafting: Insights from a systematic review and meta-analysis.
        J Am Heart Assoc. 2018; 7e009361
        • Taggart DP
        • Benedetto U
        • Gerry S
        • et al.
        Bilateral versus single internal-thoracic-artery grafts at 10 years.
        N Engl J Med. 2019; 380: 437-446
        • Thalji NM
        • Suri RM
        • Daly RC
        • et al.
        The prognostic impact of concomitant coronary artery bypass grafting during aortic valve surgery: Implications for revascularization in the transcatheter era.
        J Thorac Cardiovasc Surg. 2015; 149: 451-460
        • Beach JM
        • Mihaljevic T
        • Svensson LG
        • et al.
        Coronary artery disease and outcomes of aortic valve replacement for severe aortic stenosis.
        J Am Coll Cardiol. 2013; 61: 837-848
        • Suvarna S
        • Smith A
        • Stygall J
        • et al.
        An intraoperative assessment of the ascending aorta: A comparison of digital palpation, transesophageal echocardiography, and epiaortic ultrasonography.
        J Cardiothorac Vasc Anesth. 2007; 21: 805-809
        • Biancari F
        • Santini F
        • Tauriainen T
        • et al.
        Epiaortic ultrasound to prevent stroke in coronary artery bypass grafting.
        Ann Thorac Surg. 2020; 109: 294-301
        • Deppe AC
        • Arbash W
        • Kuhn EW
        • et al.
        Current evidence of coronary artery bypass grafting off-pump versus on-pump: A systematic review with meta-analysis of over 16,900 patients investigated in randomized controlled trialsdagger.
        Eur J Cardiothorac Surg. 2016; 49: 1031-1041
        • Smart NA
        • Dieberg G
        • King N.
        Long-term outcomes of on- versus off-pump coronary artery bypass grafting.
        J Am Coll Cardiol. 2018; 71: 983-991
        • Lamy A
        • Devereaux PJ
        • Prabhakaran D
        • et al.
        Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year.
        N Engl J Med. 2013; 368: 1179-1188
        • Furnary AP
        • Zerr KJ
        • Grunkemeier GL
        • et al.
        Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures.
        Ann Thorac Surg. 1999; 67: 352-360
        • Hruska LA
        • Smith JM
        • Hendy MP
        • et al.
        Continuous insulin infusion reduces infectious complications in diabetics following coronary surgery.
        J Card Surg. 2005; 20: 403-407
        • Lazar HL
        • Chipkin SR
        • Fitzgerald CA
        • et al.
        Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events.
        Circulation. 2004; 109: 1497-1502
        • Umpierrez G
        • Cardona S
        • Pasquel F
        • et al.
        Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: GLUCO-CABG Trial.
        Diabetes Care. 2015; 38: 1665-1672
        • Bybee KA
        • Powell BD
        • Valeti U
        • et al.
        Preoperative aspirin therapy is associated with improved postoperative outcomes in patients undergoing coronary artery bypass grafting.
        Circulation. 2005; 112: I286-I292
        • Hastings S
        • Myles P
        • McIlroy D.
        Aspirin and coronary artery surgery: A systematic review and meta-analysis.
        Br J Anaesth. 2015; 115: 376-385
        • Firanescu CE
        • Martens EJ
        • Schonberger JP
        • et al.
        Postoperative blood loss in patients undergoing coronary artery bypass surgery after preoperative treatment with clopidogrel: A prospective randomised controlled study.
        Eur J Cardiothorac Surg. 2009; 36: 856-862
        • Auer J
        • Weber T
        • Berent R
        • et al.
        A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery: The pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomized, placebo-controlled trial.
        Am Heart J. 2004; 147: 636-643
        • Ferguson Jr., TB
        • Coombs LP
        • Peterson ED
        • et al.
        Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America.
        JAMA. 2002; 287: 2221-2227
        • Motivala AA
        • Parikh V
        • Roe M
        • et al.
        Predictors, trends, and outcomes (among older patients >/=65 years of age) associated with beta-blocker use in patients with stable angina undergoing elective percutaneous coronary intervention: Insights from the NCDR registry.
        JACC Cardiovasc Interv. 2016; 9: 1639-1648
        • Zhang H
        • Yuan X
        • Zhang H
        • et al.
        Efficacy of long-term beta-blocker therapy for secondary prevention of long-term outcomes after coronary artery bypass grafting surgery.
        Circulation. 2015; 131: 2194-2201
        • Bangalore S
        • Steg G
        • Deedwania P
        • et al.
        beta-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease.
        JAMA. 2012; 308: 1340-1349
      4. European Association for Cardio-Thoracic Surgery. EACTS statement: Coronary artery revascularisation guidelines. Available at: Accessed September 6, 2022.

        • Farkouh ME
        • Domanski M
        • Sleeper LA
        • et al.
        Strategies for multivessel revascularization in patients with diabetes.
        N Engl J Med. 2012; 367: 2375-2384
        • Fearon WF
        • Zimmermann FM
        • De Bruyne B
        • et al.
        Fractional flow reserve-guided PCI as compared with coronary bypass surgery.
        N Engl J Med. 2022; 386: 128-137