Should an asymptomatic patient with an 80% Left Anterior Descending (LAD) artery lesion undergo revascularization?

Revascularization for Asymptomatic 80% LAD Lesion

Revascularization is recommended for an asymptomatic patient with an 80% LAD lesion, particularly if it involves the proximal LAD, to reduce long-term cardiovascular mortality and the risk of spontaneous myocardial infarction. 1

Evidence-Based Rationale

The 2024 European Society of Cardiology (ESC) guidelines provide clear direction on this clinical scenario with a Class I recommendation (Level B evidence):

• In patients with LVEF >35%, myocardial revascularization is recommended, in addition to guideline-directed medical therapy, for patients with functionally significant single-vessel disease involving the proximal LAD 1
• The recommendation is specifically aimed at reducing long-term cardiovascular mortality and the risk of spontaneous myocardial infarction 1

This recommendation applies even to asymptomatic patients, as the American College of Cardiology/American Heart Association (ACC/AHA) guidelines support revascularization of proximal LAD lesions for survival benefit regardless of symptom status 2.

Decision-Making Algorithm

1. Confirm hemodynamic significance

   • Perform functional assessment (FFR/iFR) to confirm the hemodynamic significance of the stenosis if not already done 1, 2
   • An 80% stenosis is likely to be functionally significant but confirmation is recommended

2. Heart Team discussion

   • For complex cases, a Heart Team approach is recommended (Class I, Level C) 1
   • Include interventional cardiology, cardiac surgery, and non-interventional cardiology representatives

3. Revascularization strategy selection

   • For isolated proximal LAD disease: Either PCI or CABG is appropriate 2
   • If multivessel disease is present: CABG is generally preferred, especially with diabetes 2
   • If CABG is chosen: The left internal mammary artery should be used for LAD revascularization 2

PCI vs. CABG Considerations

The choice between PCI and CABG should consider:

• Procedural risk: Calculate the STS score for CABG risk and SYNTAX score for anatomical complexity 1
• Long-term outcomes: While older data suggested CABG superiority, more recent evidence with drug-eluting stents shows comparable outcomes:
  • The PROTECT trial showed that proximal LAD location was associated with higher rates of myocardial infarction but no differences in death, target vessel failure, or overall MACE 3
  • However, MIDCAB (minimally invasive direct coronary artery bypass) has shown better freedom from angina and lower reintervention rates compared to PCI in some studies 4, 5

Important Caveats

• Asymptomatic status is not risk-free: Silent ischemia can lead to sudden cardiac events 2
• Patient-centered approach: The decision for revascularization and its modality should consider patient preferences and social support (Class I, Level C) 1
• Intracoronary imaging guidance: IVUS or OCT is recommended when performing PCI on anatomically complex lesions (Class I, Level A) 1
• Procedural risk assessment: Patients with physiologic risk factors (age >75, multivessel coronary disease, heart failure, etc.) may have higher risk of perioperative MI with revascularization procedures 6

The evidence strongly supports revascularization for an asymptomatic patient with an 80% LAD lesion, particularly if it involves the proximal segment, as this approach has been shown to reduce long-term cardiovascular mortality and spontaneous myocardial infarction risk.