EACTS Statement regarding 2021 AHA/ ACC/SCAI Coronary Artery Revascularization Guidelines

We would like to congratulate the American Heart Association (AHA), the American College of Cardiology (ACC) and the Society for Cardiovascular Angiography and Interventions (SCAI) for the work and effort involved in producing their recent Coronary Artery Revascularization guidelines. We appreciate the evaluation of recent trials and meta-analyses and advances on key topics and acknowledge that there can be divergent views regarding the interpretation of the evidence. After careful review, we are, however, extremely concerned regarding 2 issues:

1. Chapter 7.1 arbitrarily downgraded coronary artery bypass grafting (CABG) from a class of recommendation (COR) I to IIb in patients with stable multivessel coronary artery disease. No new randomized controlled trials are cited to support this downgrade and to reject the previously held supporting evidence [1–3] showing a convincing mortality benefit for CABG. The guidelines imply that the results may not have been favourable for the CABG subgroup in the ISCHEMIA trial. This subgroup analysis has not been published to date. Furthermore, this COR is the same (IIb) for percutaneous coronary intervention, whereas the recommendation states that ‘the usefulness of PCI to improve survival is uncertain’. The downgrading of CABG and placing percutaneous coronary intervention in the same COR do not meet our interpretation of the evidence and may lead to avoidable loss of life. These guidelines also have implications for patient care: a COR IIb entails that CABG may not be reimbursable in some countries.
2. It is additionally astonishing that no surgical association was involved in, co-authored or endorsed these guidelines. The collaborative heart team is central to the management of heart disease; it is difficult to understand how key members of the heart team are not involved in guidelines that play an essential role in our heart team discussions. It is unfathomable that guidelines on subjects key to the heart team would include only one side of the heart team.

European Association for Cardio-Thoracic Surgery (EACTS) does not support the conclusions of Chapter 7.1 and recommends that treatment decisions for multivessel coronary artery disease take into account information from the 2018 EACTS and European Society of Cardiology (ESC) Guidelines on Myocardial Revascularization exclusively. We encourage the AHA, ACC and SCAI to review the evidence accordingly.

We hope these comments will be received as a constructive call to include all voices in the heart team and to ensure rigorous methods of reviewing the evidence to update recommendations.