Summary

Consolidated update of prior PCI, CABG, STEMI, NSTE-ACS, and SIHD revascularization guidelines into a single patient-centric document. Emphasizes Heart Team decision-making, shared decision-making, equity of care, radial access, radial artery conduit over saphenous vein for second target, shorter DAPT durations with P2Y12 monotherapy transition, staged non-culprit PCI in STEMI, and CABG preference for diabetics with multivessel disease. Downgrades CABG from Class I to Class 2b for 3-vessel SIHD with preserved EF based on ISCHEMIA and contemporary trials.

Key Recommendations

Use a multidisciplinary Heart Team approach when optimal revascularization strategy is unclear, especially for left main, complex multivessel, or diabetic multivessel CAD.
For significant left main disease, CABG is indicated to improve survival; PCI is reasonable in selected patients with low-to-medium anatomic complexity (SYNTAX <33).
In diabetic patients with multivessel CAD, CABG is preferred over PCI to reduce mortality; PCI only if poor surgical candidate.
Use the radial artery (not saphenous vein) as the second conduit after LIMA-to-LAD to improve patency, MACE, and survival.
Use radial artery access for PCI in ACS and SIHD to reduce bleeding and vascular complications; radial reduces mortality in ACS.
In STEMI with multivessel disease, perform staged PCI of significant non-infarct arteries (in-hospital or within 45 days) in stable patients; avoid multivessel PCI in cardiogenic shock (CULPRIT-SHOCK).
Primary PCI is preferred over fibrinolysis for STEMI when achievable within 120 minutes; rescue PCI indicated after failed fibrinolysis.
In NSTE-ACS, use early invasive strategy (<24h) for high-risk patients (GRACE >140); immediate angiography (<2h) for hemodynamic/electrical instability.
For SIHD with 3-vessel disease and normal EF, CABG may be reasonable (Class 2b, downgraded) to improve survival; PCI survival benefit uncertain.
After PCI in SIHD, consider transition to P2Y12 inhibitor monotherapy after 1-3 months of DAPT to reduce bleeding in selected patients.
Use FFR ≤0.80 or iFR ≤0.89 to guide PCI of intermediate lesions; defer revascularization if above these thresholds.
Use newer-generation DES over BMS for nearly all PCI; calculate STS score for surgical risk and use radial access for catheterization in CKD.

Thresholds & Doses

Significant stenosis: ≥70% diameter for non-left main; ≥50% for left main
Intermediate stenosis: 40–69% diameter — assess with FFR/iFR
FFR ≤0.80 or iFR ≤0.89 indicates ischemia warranting PCI; defer if above
IVUS minimum lumen area ≥6.0 mm² (≥4.5 mm² in Asians) supports deferring left main intervention
SYNTAX score ≥33 = high complexity favoring CABG over PCI in multivessel disease
Primary PCI goal: <120 minutes from first medical contact; fibrinolysis if delay exceeds this
Staged non-infarct PCI in STEMI: within 45 days of index event
NSTE-ACS early invasive: <24 hours if GRACE >140; immediate (<2h) if unstable
Aspirin: load 162–325 mg, maintenance 75–100 mg daily (use ≤100 mg with ticagrelor)
Clopidogrel: load 600 mg (300 mg after fibrinolysis), 75 mg daily maintenance
Prasugrel: load 60 mg, 10 mg daily (5 mg if <60 kg or ≥75 years); contraindicated with prior TIA/CVA
Ticagrelor: load 180 mg, 90 mg twice daily
Cangrelor: 30 μg/kg bolus then 4 μg/kg/min infusion
UFH for PCI: 70–100 U/kg bolus targeting ACT 250–300 s
Bivalirudin: 0.75 mg/kg bolus, 1.75 mg/kg/h infusion
Enoxaparin IV during PCI: 0.5–0.75 mg/kg
Perioperative glucose target after CABG: <180 mg/dL via continuous insulin infusion
DAPT duration after PCI: standard 6–12 months; short DAPT 1–3 months acceptable in selected SIHD before transition to P2Y12 monotherapy
Hold clopidogrel/ticagrelor ≥3–5 days, prasugrel ≥7 days before CABG
Withhold GP IIb/IIIa: eptifibatide/tirofiban infusions before CABG per half-life
Older patient threshold: ≥75 years (lower prasugrel dose, increased bleeding risk)

Citations

Top 10 Take-Home Messages — core practice-changing points
Section 2.2 / Table 3 — shared decision-making and informed consent components
Section 3 / Table 4 — Heart Team factors and STS risk score
Section 4.3 — FFR/iFR thresholds (0.80/0.89) for PCI guidance
Section 5 / Figures 3-4 — STEMI infarct and non-infarct artery revascularization
Section 6 / Figure 5 — NSTE-ACS timing of invasive strategy by GRACE
Section 7 / Figure 6 — SIHD revascularization including downgrade of CABG for 3VD
Section 8.2 — CABG preferred over PCI in diabetic multivessel disease (FREEDOM)
Section 12.2 / Table 12 — radial artery as preferred second conduit; LIMA-LAD
Section 14.2 / Figure 7 / Table 9 — DAPT duration and P2Y12 monotherapy after PCI
Section 13.1 / Table 13 — perioperative insulin and sternal wound infection prevention
Section 9.3 / Table 8 — CKD best practices in catheterization laboratory