From the Guidelines
The decision between cardiac stent placement and Coronary Artery Bypass Grafting (CABG) should be based on a Heart Team approach, considering the extent and location of coronary artery disease, as well as patient-specific factors such as age, comorbidities, left ventricular function, and patient preference, with CABG generally recommended for patients with left main disease, three-vessel disease, or complex anatomical patterns, and stent placement preferred for patients with single or two-vessel disease without left main involvement 1.
Key Considerations
- The SYNTAX score is recommended to assess the anatomical complexity of disease in patients with multivessel obstructive CAD 1.
- Calculation of the STS score is recommended to estimate in-hospital morbidity and 30-day mortality after CABG 1.
- Intracoronary imaging guidance by IVUS or OCT is recommended when performing PCI on anatomically complex lesions, in particular left main stem, true bifurcations, and long lesions 1.
- Patients with diabetes often benefit more from CABG due to better long-term outcomes 1.
Patient-Specific Factors
- Left ventricular function: CABG is recommended for patients with LVEF ≤35% and multivessel CAD 1.
- Age and comorbidities: should be considered in the decision-making process, with a Heart Team approach recommended for complex clinical cases 1.
- Patient preference: should be taken into account, with informed and shared decisions recommended 1.
Treatment Outcomes
- CABG provides more durable revascularization but involves a more invasive procedure with longer recovery 1.
- Stent placement offers quicker recovery with less initial procedural risk but may require repeat procedures 1.
- Optimal medical therapy, including antiplatelet agents, statins, blood pressure management, and lifestyle modifications, is essential for improving long-term outcomes regardless of the chosen intervention 1.
From the Research
Guidelines for Cardiac Stent vs CABG
The decision between cardiac stent placement and Coronary Artery Bypass Grafting (CABG) in patients with coronary artery disease depends on several factors, including the severity of the disease, the number of diseased vessels, and the presence of certain clinical characteristics.
- The studies 2, 3, 4, 5, 6 suggest that CABG is associated with higher adjusted rates of long-term survival than stenting for patients with multivessel coronary artery disease.
- Patients with diabetes mellitus and multivessel coronary artery disease may benefit from CABG, as it is associated with a lower risk of major adverse cardiac events and repeat revascularization 4, 5.
- The SYNTAX score II, which takes into account both anatomical and clinical characteristics, can help guide decision making between CABG and PCI 6.
- The choice between CABG and PCI should be made on a case-by-case basis, considering factors such as the severity of coronary disease, patient characteristics, and local expertise 5.
Key Factors to Consider
- Severity of coronary disease: CABG may be preferred for patients with complex coronary lesions and anatomy, while PCI may be suitable for less complicated disease 5, 6.
- Presence of diabetes: CABG may be the preferred treatment option for patients with diabetes and multivessel coronary artery disease 4, 5.
- Clinical characteristics: Factors such as age, creatinine clearance, left ventricular ejection fraction, and presence of peripheral vascular disease or chronic obstructive pulmonary disease should be considered when making treatment decisions 6.
Treatment Outcomes
- CABG is associated with lower rates of repeat revascularization and major adverse cardiac events compared to PCI 2, 3, 4, 5.
- PCI is associated with a higher risk of repeat revascularization, but may be suitable for patients with less complicated coronary disease or those who are at high surgical risk 5.
- The SYNTAX score II can help predict 4-year mortality and guide treatment decisions 6.