Coronary revascularization
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]
Overview
Historical Perspective
Classification
Coronary revascularization may refer to;
Indications
- Treatment decisions regarding coronary revascularization should be done regardless of sex, race, and ethnicity.[1]
- Decision regarding coronary revascularization should be patient-centered, meaning that physicians should consider patient's wishes, health literacy, and cultural believes.[1]
- Based on ACC/AHA/SCAI 2021 guideline, for patients with unclear optimal treatment strategy a Heart Team including an interventional cardiologist, cardiac surgeon, and clinical cardiologist is recommended to assess the patient's outcome. The following table demonstrates factors that can be considered by the Heart Team:[1]
| Coronary Anatomy | *Left main disease *Multivessel disease *Complicated anatomy (such as bifurcation disease, and high SYNTAX score |
|---|---|
| Comorbidities | *Coagulopathy *Frailty *Diabetes *Valvular heart disease *Cancer *Systolic dysfunction *End-stage renal disease *Aortic aneurysm *Calcified aorta *Immunosuppression *Chronic obstructive pulmonary disease *History of cerebral stroke *Debilitating neurological disorders *Cirrhosis/liver disease |
| Procedure | *Access site for percutaneous coronary intervention (PCI) *Risk of surgery *Local and regional clinical outcomes *Risk of percutaneous coronary intervention (PCI) |
| Patient | *Patient preferences, religional believes, education, and knowledge *Incompliant to dual antiplatelet therapy *Patient social supports *Unstable presentation or shock |
Coronary Anatomy
- Based on ACC 2021 guideline, coronary angiography is still the default method to determine coronary anatomy and stenosis degree.[1]
- Significant stenosis is one of the indications for the revascularization procedure, which has been defined as the following observations in coronary angiography:[1]
- The fact that whether visually estimated diameter stenosis or quantitative coronary angiography can better predict the the functional significance of a coronary stenosis is controversial. [2]
- Although the lesion's length can affect the ischemia severity, there are no standard cutoffs for length of the lesions when sever stenosis is determined.
What Procedure to Choose?
SYNTAX Score
- SYNTAX score derived from a clinical trial with the same name which predicts the grade of the anatomic complexity and can be used as a decision-making tool. This score is a guide for the selection of a revascularization procedure in patients with multivessel coronary artery disease.[3]
Fractional flow reserve and instantaneous wave-Free Ratio
- Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are commonly used to assess the lesion significant. Fractional flow reserve (FFR) compares the maximal blood flow distal to the lesion to the normal maximal blood flow. On the other hand iFR compares the instantaneous wave-free ratio of the coronary pressure distal to the lesion during the diastole with the aortic pressure.[1]
- Reported in numbers of trials which used FFR, FFR-guided PCI was successful in lowering the revascularization rate in patients with stable coronary artery disease and functionally significant stenosis.[4][5][6]
- In one of these trials patients with abnormal FFR significantly benefited from PCI over medical therapy with lower rate of ischemia-driven revascularization.
- FFR-guided revascularization with CABG was more off-pump with fewer anastomosis compared to CABG with angiogram-guided revascularization in one of the clinical trials.[7][1]
- iFR measure does not require the administration of adenosine has been also studied in clinical trials. Results supported that this measure is not inferior to FFR and also showed less adverse outcome related to the procedure.[8]
Outcome
- After controlling baseline comorbidities and treatment strategies, outcome of coronary revascularization were same among different races as well as males and females.[1][9][10]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "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. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check
|pmid=value (help). - ↑ Adjedj J, Xaplanteris P, Toth G, Ferrara A, Pellicano M, Ciccarelli G; et al. (2017). "Visual and Quantitative Assessment of Coronary Stenoses at Angiography Versus Fractional Flow Reserve: The Impact of Risk Factors". Circ Cardiovasc Imaging. 10 (7). doi:10.1161/CIRCIMAGING.117.006243. PMID 28687539.
- ↑ Garg S, Serruys PW, Silber S, Wykrzykowska J, van Geuns RJ, Richardt G; et al. (2011). "The prognostic utility of the SYNTAX score on 1-year outcomes after revascularization with zotarolimus- and everolimus-eluting stents: a substudy of the RESOLUTE All Comers Trial". JACC Cardiovasc Interv. 4 (4): 432–41. doi:10.1016/j.jcin.2011.01.008. PMID 21511223.
- ↑ De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z; et al. (2012). "Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease". N Engl J Med. 367 (11): 991–1001. doi:10.1056/NEJMoa1205361. PMID 22924638.
- ↑ De Bruyne B, Fearon WF, Pijls NH, Barbato E, Tonino P, Piroth Z; et al. (2014). "Fractional flow reserve-guided PCI for stable coronary artery disease". N Engl J Med. 371 (13): 1208–17. doi:10.1056/NEJMoa1408758. PMID 25176289.
- ↑ Xaplanteris P, Fournier S, Pijls NHJ, Fearon WF, Barbato E, Tonino PAL; et al. (2018). "Five-Year Outcomes with PCI Guided by Fractional Flow Reserve". N Engl J Med. 379 (3): 250–259. doi:10.1056/NEJMoa1803538. PMID 29785878.
- ↑ Bruno F, D'Ascenzo F, Marengo G, Manfredi R, Saglietto A, Gallone G; et al. (2021). "Fractional flow reserve guided versus angiographic guided surgical revascularization: A meta-analysis". Catheter Cardiovasc Interv. 98 (1): E18–E23. doi:10.1002/ccd.29427. PMID 33315297 Check
|pmid=value (help). - ↑ Bruner CA, Webb RC (1990). "Increased vascular reactivity to Bay K 8644 in genetic hypertension". Pharmacology. 41 (1): 24–35. doi:10.1159/000138696. PMID 0.1056/NEJMoa1700445 Check
|pmid=value (help). - ↑ O'Donoghue M, Boden WE, Braunwald E, Cannon CP, Clayton TC, de Winter RJ; et al. (2008). "Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction: a meta-analysis". JAMA. 300 (1): 71–80. doi:10.1001/jama.300.1.71. PMID 18594042. Review in: ACP J Club. 2008 Nov 18;149(5):7 Review in: Evid Based Med. 2009 Feb;14(1):19
- ↑ Tamis-Holland JE, Palazzo A, Stebbins AL, Slater JN, Boland J, Ellis SG; et al. (2004). "Benefits of direct angioplasty for women and men with acute myocardial infarction: results of the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B) Angioplasty Substudy". Am Heart J. 147 (1): 133–9. doi:10.1016/j.ahj.2003.06.002. PMID 14691431.