What are the treatment options for triple vessel coronary artery disease?

Treatment Options for Triple Vessel Coronary Artery Disease

Primary Treatment Recommendation

For patients with triple vessel coronary artery disease, coronary artery bypass grafting (CABG) is the superior revascularization strategy over both percutaneous coronary intervention (PCI) and medical therapy alone, providing significantly lower rates of death (9.2% vs 14.6% at 5 years), myocardial infarction (4.0% vs 9.2%), and repeat revascularization (12.6% vs 25.4%). 1, 2

---

Treatment Algorithm Based on Clinical Characteristics

Step 1: Assess Presence of Diabetes

If diabetes is present:

• CABG is mandatory regardless of anatomic complexity or SYNTAX score 1, 3
• CABG improves symptoms and outcomes compared to both medical therapy alone and PCI (Class I, Level A recommendation) 1
• The survival advantage of CABG over PCI is even more pronounced in diabetic patients (hazard ratio 2.30 vs 1.51 in non-diabetics) 2

If diabetes is absent:

• Proceed to Step 2 for anatomic complexity assessment 1, 3

Step 2: Calculate SYNTAX Score to Determine Anatomic Complexity

SYNTAX score ≥33 (high complexity):

• CABG is the mandatory choice 3, 2
• PCI results in significantly higher rates of death, MI, and repeat revascularization in this population 2

SYNTAX score 23-32 (intermediate complexity):

• CABG is strongly preferred 1, 2
• PCI may be considered only if complete revascularization equivalent to CABG can be achieved (Class IIa recommendation) 1

SYNTAX score ≤22 (low complexity):

• Both CABG and PCI are acceptable if complete revascularization is achievable 1, 3
• PCI is recommended as an alternative given lower invasiveness and non-inferior survival in this specific subset (Class I, Level A recommendation) 1
• However, PCI still results in significantly higher repeat revascularization rates (25.4% vs 12.6%) even in low SYNTAX score patients 2

Step 3: Assess Left Ventricular Function

LVEF ≤35%:

• CABG is mandatory to improve long-term survival (Class I, Level B recommendation) 4

LVEF 35-50%:

• CABG is strongly preferred 1
• The survival benefit of CABG is even greater when LVEF is <50% 1, 4

LVEF >50% (preserved function):

• CABG is recommended over medical therapy alone to improve symptoms, survival, and other outcomes (Class I, Level A recommendation) 1
• For patients with low anatomic complexity (SYNTAX ≤22) and no diabetes, PCI providing equivalent completeness of revascularization is an acceptable alternative 1

Step 4: Assess Surgical Risk

Low surgical risk:

• CABG is recommended over medical therapy alone (Class I, Level A recommendation) 1

High surgical risk (STS-predicted mortality ≥5%, severe COPD, prior stroke, prior cardiac surgery):

• If SYNTAX score ≤22 and complete revascularization achievable: PCI is reasonable 3
• If SYNTAX score >22: Heart Team discussion required, but PCI may be considered over medical therapy alone (Class IIb, Level B recommendation) 1

---

Specific Clinical Scenarios

Triple Vessel Disease with Moderate Mitral Regurgitation and LV Dysfunction

• CABG is strongly preferred over PCI 5
• PCI is associated with significantly increased risk of cardiovascular death and heart failure hospitalization (HR 1.85) in patients with moderate MR 5
• In patients with no-mild MR, outcomes between PCI and CABG are more comparable 5

Non-ST Elevation Acute Coronary Syndrome with Triple Vessel Disease

• CABG is independently associated with lower risk of long-term cardiac death, revascularization, and major adverse cardiovascular events compared with PCI 6
• Both CABG and PCI are superior to medical therapy alone 6
• Immediate coronary angiography followed by appropriate revascularization is recommended for high-risk patients 7

---

Surgical Technique Considerations When CABG is Selected

• Use left internal mammary artery (LIMA) to left anterior descending (LAD) artery in every CABG procedure (long-term patency rates exceeding 90% at 10 years) 4
• Use radial artery as surgical conduit in preference to saphenous vein for the second most important target vessel 4
• Complete revascularization should be the goal, as it is independently associated with significant reduction in major adverse cardiac and cerebrovascular events 4

---

Alternative Strategy: Hybrid Coronary Revascularization

• Hybrid coronary revascularization (HCR) combining LIMA to LAD with PCI for non-LAD lesions may be considered in select patients 8
• HCR demonstrates similar 8-year mortality (5.0%) compared to CABG (4.0%) or multivessel PCI (9.0%) in propensity-matched cohorts 8
• HCR should only be considered if a low residual SYNTAX score can be achieved 8

---

Critical Pitfalls to Avoid

• Do not defer CABG in asymptomatic or mildly symptomatic patients with triple vessel disease, as the survival benefit exists regardless of symptom severity 3
• Do not withhold CABG in elderly patients based on age alone when surgical risk is acceptable 3
• Do not perform PCI in diabetic patients with triple vessel disease expecting equivalent outcomes to CABG, as CABG provides superior outcomes in this population 3, 2
• Do not choose PCI over CABG based solely on shorter initial recovery time without considering the significantly higher rates of repeat revascularization and long-term adverse outcomes 2
• Do not use medical therapy alone when revascularization is feasible, as both CABG and PCI are superior to medical therapy in reducing adverse outcomes 6

---

Heart Team Discussion

• A multidisciplinary Heart Team discussion is recommended to select the most appropriate revascularization modality based on patient profile, coronary anatomy, procedural factors, LVEF, and surgical risk 4
• This is particularly important for patients with intermediate SYNTAX scores (23-32), high surgical risk, or complex clinical scenarios 1, 4