The 2021 Coronary Artery Revascularization Guideline updates recommendations based on new evidence for when to do a procedure or surgery to open heart arteries, how, and what patients can do afterward to stay healthy.
Here’s a summary of key points for patients about the guideline.
What Patients Need to Know
Coronary artery disease happens when the coronary arteries — the blood vessels that supply blood rich with oxygen to the heart — become damaged or diseased. Usually, this is caused by a buildup of fat and cholesterol (also called plaque) in the walls of the arteries. This plaque is the result of aging and genetics, yet is heavily affected by diet, exercise, smoking and diabetes.
In coronary artery disease, or CAD, the heart muscle may not be able to get the blood and oxygen it needs. This can result in chest pain (angina) and accompanying symptoms (such as shortness of breath) or a heart attack. There are a number of treatment options for CAD including lifestyle changes, medications, surgery or minimally invasive procedures.
Coronary artery “revascularization” involves a procedure or surgery to improve blood flow to the heart. There are two main ways this is done:
- Placing a stent to prop the artery open, typically through a small tube placed in a blood vessel in the wrist (percutaneous coronary intervention)
- Having open-heart surgery, or coronary artery bypass graft (CABG) surgery, to re-route blood around the blocked or narrowed area by using other veins or arteries in the body
The right treatment for each person will depend on symptoms, where the blockage is and how much it is blocking flow, and the number of blood vessels involved. It also will depend on how high-risk a person’s heart disease is and other factors, such as age, other medical conditions, and the patient’s informed preferences and values.
Patients are Important Part of Heart Team Decision-Making
The Heart Team traditionally is a group of doctors that meets to review the differences among treatment options, taking into account the individual patient’s history. Making a final decision on a treatment plan for CAD or heart attack requires an informed patient as part of the Heart Team.
It is important for patients to be invited to play an active role in learning about their condition, weighing the treatment options the Heart Team has selected and – once informed on the differences among the options – expressing their values and preferences.
In addition to a heart doctor, other health professionals on the team might include their primary care doctor, heart surgeon, imaging specialists, dietitian, and patient educators. This Heart Team approach is especially needed for patients with complex coronary disease or who have heart disease and other health conditions at the same time.
When to Intervene
For some patients with stable ischemic heart disease, new evidence shows that deciding whether to intervene with surgery or PCI, or to focus on medical therapy, diet and exercise changes, can be complex. Stable ischemic heart disease means there are clogged coronary arteries, but not enough to cause a heart attack. In these cases, medications may help.
In cases when there are several options and the benefits of each are less clear, shared decision-making discussions with members of the Heart Team and the patient and their family can help to select the best path forward.
Staying Healthy Afterward
To help patients stay healthy after their procedures, adopting healthy habits (for example, eating better, moving more, getting enough sleep, being mindful/controlling stress, and connecting with others) and following a heart treatment plan are important. For more details, visit CardioSmart.org/HealthyLiving. It helps for patients to know why they are taking each medication, the dose (or amount) and for how long they should stay on that medication.
In addition, it is recommended that patients talk with their Heart Team about:
- Cardiac rehabilitation: Taking part in a cardiac rehabilitation program helps keep people healthy and out of the hospital. It should be a high priority for anyone who has had a procedure to restore blood flow to the heart. Not only will cardiac rehab help patients feel healthy and strong again, but it also can help them live longer. The program includes counseling on how to exercise, eat heart healthy, manage stress and quit smoking. It also teaches patients how to take better control of their health.
- Not smoking: Continuing to smoke after a heart procedure has been associated with poor outcomes, according to the guideline. Patients should ask their health care team about medications and quit-smoking programs that can help. Patients can make a plan today at Smokefree.gov.
- Emotional health: People with heart disease or who are recovering from a heart attack or cardiac procedures are at greater risk of becoming depressed. For people with heart disease, depression is harmful not only because of the distress it causes, but it also puts them at risk of future heart problems, including another heart attack or dying. It can also delay recovery from heart procedures. It is recommended that if patients have feelings such as anxiety or sadness that linger beyond a couple of weeks or months in the setting of CAD, they should ask about getting screened for depression.
Reducing Health Disparities
Despite advances in identifying and treating CAD, disparities in outcomes based on sex, and race and ethnicity persist. For example, studies show that Black patients and those of South Asian descent with CAD have poorer outcomes than White patients. Also, non-White patients are less likely to receive intervention to restore blood flow.
More research is needed to find out how best to reduce these disparities. Acknowledging them is a first step. All patients are encouraged to see a primary care doctor for screening for CAD risk factors, including high blood pressure, high cholesterol, diabetes, and overweight or obesity. For more information, visit CardioSmart.org/CAD. Patients are also encouraged to ask their health care teams about ongoing research trials that they can participate in to advance our understanding of how to prevent and treat CAD.
“2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization,” Journal of the American College of Cardiology, Dec. 9, 2021.
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