The Japanese Society for Cardiovascular Surgery, The Japanese Association for
Thoracic Surgery and The Japanese Association for Coronary Artery Surgery Do Not
Endorse Chapter 7.1 in the 2021 ACC/AHA/SCAI Coronary Revascularization
Guidelines
The new ACC/AHA/SCAI Coronary Revascularization Guidelines downgraded coronary
artery bypass grafting (CABG) from a class of recommendation (COR) I to IIb in patientswith stable ischemic heart disease (SIHD), normal ejection fraction, significant stenosis
in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for
CABG. The ISCHEMIA trial was cited by the guidelines committee to support thesedowngrades.
1. CABG and PCI are treatment modalities with different treatment effects. CABG has
a preventive effect on myocardial infarction and all-cause mortality [Level ofEvidence A]1-5, even in the current era of PCI and optimal medical therapy including
statin and ARB. As for the treatment effect of PCI on stable coronary artery disease,in contrast, no randomized trial has yet demonstrated that the strategy of initial PCI
is more effective in preventing myocardial infarction or all-cause mortality than thestrategy of initial medical therapy alone. Since the randomized trial was an ITT(intention to treat) analysis, this does not mean that PCI is not necessary in thelifelong treatment strategy for stable coronary artery disease, since even patients in
the initial medication strategy group underwent additional PCI if necessary, during
the follow-up period.
2. We acknowledge the results of the ISCHEMIA trial. From the standpoint of cardiac
surgeons, our interpretation of the results of this trial is summarized as follows. First,
the initial invasive group included PCI (74%) and CABG (26%), and therefore theresults were more influenced by treatment effect of PCI rather than CABG. Second,since the prevalence of proximal LAD stenosis for which CABG (ITA-LAD) is effective
is 36.2% in this trial, CABG should have been selected at a higher rate (higher than26%). Third, the median was follow-up 3.2 years, which is too short for the treatment
effects of CABG to become apparent. Considering together, we think that this trial
has no relevant impact on the COR for CABG.
3. We are disappointed that no surgical association such as AATS/STS was involved indeveloping this new guideline. In fact, the AATS/STS, EACTS, and LACES havealready declared that they do not endorse Chapter 7.1 of this new guideline. We
acknowledge that there can be divergent standpoints regarding the interpretation ofthe evidence. For this new guideline, surgeons were a minority on the writingcommittee and had limited leverage in the consensus building process. We strongly
believe that there should be equal representation of surgeons and cardiologists in thewriting committee of a document that addresses a procedure-based approach.
Again, we do not endorse Chapter 7.1 and Figure 6 (Revascularization in Patients With SIHD)
in the 2021 ACC/AHA/SCAI Coronary Revascularization Guidelines. We support the2018 ESC/EACTS Guidelines on myocardial revascularization and the 2018 Japan
Guideline, which have a Class I for CABG in patients with SIHD, normal ejection
fraction, and significant stenosis in 3 major coronary arteries.
January 21, 2022

Hitoshi Yokoyama MD, President
On behalf of the Japanese Society for Cardiovascular Surgery

Yoshiki Sawa MD, President
On behalf of the Japanese Association for Thoracic SurgeryHirokuni Arai MD, President
On behalf of the Japanese Association for Coronary Artery Surgery
Acknowledgment:
We appreciate the contribution of following cardiac surgeons for establishment of thisstatement: Hitoshi Yaku, MD and Satoshi Numata, MD, Kyoto Prefecture Medical
University, Takayuki Ohno, MD, Mitsui Memorial Hospital, Tomohiro Mizuno, MD,
Tokyo Medical and Dental University, and we also greatly appreciate Faisal Bakaeen,
MD, Cleveland Clinic, USA for reviewing this statement.

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