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Table 1. Selected recommendations for revascularization of the infarct and non-infarct arteries in patients with STEMI from the 2021
ACC/AHA/SCAI guidelines [26]

Class of recommendation Level of evidence Recommendation
Recommendations for revascularization of the infarct artery in patients with STEMI
1 B “In patients with STEMI and cardiogenic shock or
hemodynamic instability, PCI or CABG (when PCI is not
feasible) is indicated to improve survival, irrespective of
the time delay from MI onset.”
1 B “In patients with STEMI who have mechanical
complications (e.g. ventricular septal rupture, mitral valve
insufficiency because of papillary muscle infarction or
rupture, or free wall rupture), CABG is recommended at
the time of surgery, with the goal of improving survival.”
2a B “In patients with STEMI in whom PCI is not feasible or
successful, with a large area of myocardium at risk,
emergency or urgent CABG can be effective as a
reperfusion modality to improve clinical outcomes.”
3 (Harm) C “In patients with STEMI, emergency CABG should not be
performed after failed primary PCI:
-In the absence of ischemia or a large area of myocardium
at risk, or
-If surgical revascularization is not feasible because of a
no-reflow state or poor distal targets.”
Recommendations for revascularization of the non-infarct artery in patients with STEMI
2a C “In selected patients with STEMI with complex multivessel
non-infarct artery disease, after successful primary PCI,
elective CABG is reasonable to reduce the risk of cardiac
events.”
STEMI: ST-Elevation myocardial infarction; PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; MI: myocardial
infarction.

Table 2. Selected recommendations for revascularization of the infarct and non-infarct arteries in patients with Acute Coronary
Syndromes from the 2023 ESC guidelines [30]

Class of recommendation Level of evidence Recommendation
1 B “Emergency CABG is recommended for ACS-related CS if
PCI of the IRA is not feasible/unsuccessful.”
2a C “Coronary artery bypass grafting should be considered in
patients with an occluded IRA when PPCI is not
feasible/unsuccessful and there is a large area of
myocardium in jeopardy.”
1 B “It is recommended to base the revascularization strategy
(IRA PCI, multivessel PCI/CABG) on the patient’s clinical
status and comorbidities, as well as their disease
complexity, according to the principles of management of
myocardial revascularization.”
1 C “If patients presenting with ACS stop DAPT to undergo
CABG, it is recommended they resume DAPT after surgery
for at least 12 months.”

ACS: Acute coronary syndrome; CABG: coronary artery bypass grafting; CS: cardiogenic shock; DAPT: dual-antiplatelet therapy; PCI:
percutaneous coronary intervention; IRA: infarct-related artery.

Bernard et al. performed a large single-center retrospective cohort study to evaluate the impact of the timing
[31]
of surgical revascularization on mortality in 477 stable patients after myocardial infarction . The overall
30-day mortality of the cohort was 7%, and it was significantly higher (14%) in patients who underwent
surgery within 4 days of the initial presentation. Risk factors for mortality in this study included older age,
pre-operative renal failure, peripheral vascular disease, and pre-operative ischemic recurrence. Left
ventricular function, type of AMI, and perioperative transfusions were not linked with mortality. These