From the Guidelines
The preferred treatment option between Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI) is CABG for patients with complex multivessel disease, left main coronary artery disease, or diabetes with multivessel involvement, as it offers better long-term outcomes and reduced need for repeat revascularization, as recommended by the 2024 ESC guidelines 1. The choice between CABG and PCI depends on various factors, including the patient's coronary anatomy, comorbidities, and clinical presentation.
- CABG is generally preferred for patients with:
- Complex multivessel disease
- Left main coronary artery disease
- Diabetes with multivessel involvement
- PCI is typically recommended for patients with:
- Single or less complex multivessel disease
- Acute coronary syndromes requiring immediate intervention
- High surgical risk
- Patient preference for a less invasive approach The decision should involve a Heart Team discussion including a cardiac surgeon and interventional cardiologist, as suggested by the 2023 AHA/ACC clinical performance and quality measures for coronary artery revascularization 1. Before either procedure, patients should receive optimal medical therapy, including aspirin, statins, and beta-blockers. Following PCI, dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor is required for at least 6-12 months. CABG provides more complete revascularization and better protection against future lesions, while PCI offers quicker recovery and fewer short-term complications. The patient's age, frailty, life expectancy, and personal preferences should also factor into this important decision, as emphasized by the 2024 ESC guidelines 1. In patients with left main disease, CABG is recommended over PCI, given the lower risk of spontaneous myocardial infarction and repeat revascularization, unless the patient has a low complexity SYNTAX score (≤22), in which case PCI may be considered as an alternative 1. Similarly, in patients with multivessel disease and diabetes, CABG is recommended over PCI to improve symptoms and outcomes, unless the patient is at very high surgical risk, in which case PCI may be considered 1.
From the Research
Overview of Treatment Options
The preferred treatment option between Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI) depends on various factors, including the severity of coronary artery disease, presence of comorbidities such as diabetes, and individual patient characteristics.
Patient Characteristics and Treatment Outcomes
- Patients with multivessel disease, especially those with diabetes mellitus, left ventricular systolic dysfunction, or complex lesions, tend to have better outcomes with CABG 2, 3, 4, 5.
- PCI is often preferred for patients with single-vessel or low-risk multivessel disease 2.
- In patients with triple-vessel disease and left ventricular dysfunction, CABG is associated with lower risks of cardiac death, repeat revascularization, and major adverse cardiovascular and cerebrovascular events (MACCE) compared to PCI 3.
- For diabetic patients with complex coronary artery disease, CABG reduces risks of myocardial infarction, cardiac death, and need for repeat revascularization 4, 5.
Specific Considerations for Diabetic Patients
- Diabetic patients with left main coronary disease and/or three-vessel disease tend to have better outcomes with CABG, especially those with higher SYNTAX scores or more complex lesions 5, 6.
- PCI may be appropriate for diabetic patients with less extensive disease or those with limited life expectancy or high surgical risk 6.
General Recommendations
- A 'heart team' approach is recommended to select an evidence-based, yet individualized, revascularization strategy for all patients with complex coronary artery disease 2.
- Optimal medical therapy is important for all patients with coronary artery disease, regardless of the mode of revascularization 2.