What are the European Society guidelines for managing patients with complex coronary artery disease, including those with triple vessel disease?

European Society Guidelines for Complex Coronary Artery Disease and Triple Vessel Disease

In patients with triple vessel disease and preserved left ventricular function (LVEF >35%), myocardial revascularization is mandatory in addition to guideline-directed medical therapy to improve long-term survival, reduce cardiovascular mortality, and decrease the risk of spontaneous myocardial infarction. 1

Revascularization Strategy Based on Clinical Profile

For Patients with LVEF >35%

CABG is the preferred revascularization strategy for triple vessel disease, particularly in the following scenarios:

• Patients with diabetes mellitus: CABG is superior to both medical therapy alone and PCI for improving symptoms and outcomes 1
• Patients without diabetes but with three-vessel disease: CABG improves symptoms, survival, and other outcomes compared to medical therapy alone 1
• Low-to-intermediate anatomic complexity (SYNTAX score ≤22): PCI is acceptable as an alternative to CABG when equivalent completeness of revascularization can be achieved, given its lower invasiveness and generally non-inferior survival 1

For Patients with LVEF ≤35%

CABG is strongly recommended over medical therapy alone to improve long-term survival in surgically eligible patients with multivessel CAD and reduced ejection fraction 1. The decision requires:

• Careful Heart Team evaluation of coronary anatomy 1
• Assessment of correlation between coronary disease and LV dysfunction 1
• Evaluation of comorbidities, life expectancy, and individual risk-to-benefit ratio 1
• PCI may be considered only in selected high surgical risk or inoperable patients 1

Mandatory Pre-Procedural Assessment

Before any revascularization decision, the following assessments are required:

• SYNTAX score calculation to assess anatomical complexity of disease 1
• STS score calculation to estimate in-hospital morbidity and 30-day mortality after CABG 1
• Intracoronary pressure measurement (FFR or iFR) or computation (QFR) to guide lesion selection for intervention in multivessel disease 1

Heart Team Consultation

A multidisciplinary Heart Team approach is essential for complex coronary disease decision-making, though immediate PCI of the culprit lesion does not require Heart Team consultation in acute settings 1. The Heart Team should evaluate:

• Patient clinical status and comorbidities 1
• Disease severity and distribution 1
• Angiographic lesion characteristics including SYNTAX score 1
• Local expertise and outcomes for both surgical and interventional approaches 1

Guideline-Directed Medical Therapy (Essential for All Patients)

Regardless of revascularization strategy, all patients require:

Antithrombotic Therapy

• Aspirin 75-100 mg daily in patients with previous MI or revascularization 1
• Clopidogrel 75 mg daily as alternative in aspirin intolerance 1
• Post-PCI: Aspirin plus clopidogrel for 6 months following coronary stenting 1

Lipid Management

• Statins are mandatory in all patients 1
• Add ezetimibe if LDL goals not achieved with maximum tolerated statin dose 1
• Add PCSK9 inhibitor for very high-risk patients not reaching goals on statin plus ezetimibe 1

Symptom Control

• Beta-blockers and/or calcium channel blockers as first-line for heart rate and symptom control 1
• Short-acting nitrates for immediate relief of effort angina 1
• ACE inhibitors (or ARBs) in presence of heart failure, hypertension, or diabetes 1

Gastrointestinal Protection

• Proton pump inhibitors for patients on aspirin monotherapy, DAPT, or OAC monotherapy who are at high risk of gastrointestinal bleeding 1

Technical Considerations for PCI in Complex Disease

When PCI is selected for complex anatomy:

• Intracoronary imaging guidance by IVUS or OCT is mandatory for anatomically complex lesions, particularly left main stem, true bifurcations, and long lesions 1
• FFR/iFR measurement at procedure end should be considered to identify patients at high risk of persistent angina and subsequent clinical events 1

Lifestyle and Rehabilitation

• Exercise-based cardiac rehabilitation is mandatory to reduce all-cause and cardiovascular mortality 1
• Annual influenza vaccination, especially in elderly patients 1
• Cognitive behavioral interventions to achieve healthy lifestyle changes 1
• Multidisciplinary team involvement (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, pharmacists) 1

Critical Pitfalls to Avoid

• Never perform ICA solely for risk stratification without intent to revascularize 1
• Never use nitrates in hypertrophic obstructive cardiomyopathy or with phosphodiesterase inhibitors 1
• Never use ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and OAC 1
• Do not perform routine immediate revascularization of non-culprit lesions in NSTE-ACS patients with multivessel disease presenting with cardiogenic shock 1

Follow-Up Protocol

• Review patient response to medical therapies at 2-4 weeks after drug initiation 1
• Patient education about disease, risk factors, and treatment strategy is mandatory 1