What is the most appropriate choice?

Management of Chronic Coronary Syndrome: Revascularization Recommendations

In patients with chronic coronary syndrome (CCS) and functionally significant three-vessel disease with preserved left ventricular ejection fraction (LVEF >35%), coronary artery bypass grafting (CABG) is recommended over medical therapy alone to improve long-term survival and reduce cardiovascular mortality and risk of spontaneous myocardial infarction. 1

Revascularization Recommendations Based on Coronary Anatomy

Left Main Disease

• CABG is recommended over medical therapy alone to improve survival in patients with significant left main coronary stenosis 1
• CABG is the preferred revascularization method over percutaneous coronary intervention (PCI) due to lower risk of spontaneous myocardial infarction and repeat revascularization 1
• For left main coronary stenosis of low complexity (SYNTAX score ≤22), PCI is an acceptable alternative to CABG when equivalent completeness of revascularization can be achieved 1

Three-Vessel Disease

• In patients with significant three-vessel disease and preserved LVEF, CABG is recommended over medical therapy alone to improve survival and outcomes 1
• For three-vessel disease of low-to-intermediate anatomic complexity where PCI can provide similar completeness of revascularization to CABG, PCI is a reasonable alternative given its lower invasiveness 1

Single or Two-Vessel Disease Involving Proximal LAD

• Myocardial revascularization (CABG or PCI) is recommended, in addition to guideline-directed medical therapy, for patients with functionally significant single- or two-vessel disease involving the proximal left anterior descending (LAD) artery 1
• This recommendation aims to reduce long-term cardiovascular mortality and risk of spontaneous myocardial infarction 1

Patients with Reduced LVEF (≤35%)

• In surgically eligible CCS patients with multivessel CAD and LVEF ≤35%, CABG is recommended over medical therapy alone to improve long-term survival 1
• For all patients with LVEF ≤35%, careful evaluation by a Heart Team is recommended to choose between revascularization or medical therapy alone 1

Decision-Making Process

Heart Team Approach

• For complex cases, especially when CABG and PCI hold the same level of recommendation, a Heart Team discussion is recommended 1
• The Heart Team should include representatives from interventional cardiology, cardiac surgery, non-interventional cardiology, and other relevant specialties 1

Risk Assessment Tools

• STS score calculation is recommended to estimate in-hospital morbidity and 30-day mortality after CABG 1
• SYNTAX score calculation is recommended to assess anatomical complexity of disease in patients with multivessel obstructive CAD 1

Imaging and Pressure Measurement Guidance

• Intracoronary imaging guidance (IVUS or OCT) is recommended when performing PCI on anatomically complex lesions, particularly left main stem, true bifurcations, and long lesions 1
• Intracoronary pressure measurement (FFR or iFR) or computation (QFR) is recommended to guide lesion selection for intervention in patients with multivessel disease 1

Patient-Centered Decision Making

• The decision for revascularization and its modality should be patient-centered, considering patient preferences, health literacy, cultural circumstances, and social support 1
• Patients should receive complete information about benefits, risks, therapeutic consequences, and alternatives to revascularization as part of shared clinical decision-making 1

Conclusion

Based on the 2024 ESC guidelines, CABG is the recommended treatment for patients with CCS and functionally significant three-vessel disease with preserved LVEF to improve long-term survival and reduce cardiovascular mortality and risk of spontaneous myocardial infarction.