What is the recommended treatment approach for an older patient with tri-vessel (three-vessel) disease, significant stenosis, and multiple comorbid conditions such as diabetes, hypertension, and previous myocardial infarction: percutaneous coronary intervention (PCI) with drug-eluting stents or coronary artery bypass grafting (CABG)?

CABG vs PCI for Triple Vessel Disease

For an older patient with triple vessel disease, significant stenosis, and multiple comorbidities including diabetes, hypertension, and previous myocardial infarction, CABG is the recommended treatment over PCI to improve survival, reduce myocardial infarction, and decrease repeat revascularization. 1, 2

Primary Decision Framework: Diabetes Status

Diabetes is the single most important factor that mandates CABG over PCI in triple vessel disease, regardless of anatomic complexity. 1

• In diabetic patients with multivessel disease, CABG reduces 5-year major adverse cardiac and cerebrovascular events (MACCE) to 18.7% compared to 26.6% with PCI (P = 0.005). 3
• The European Society of Cardiology provides Class I, Level A evidence that CABG is recommended over both medical therapy and PCI in diabetic patients with triple vessel disease. 1
• CABG with left internal mammary artery (LIMA) grafting to the LAD is particularly beneficial in diabetic patients with multivessel disease. 1

Anatomic Complexity Assessment: SYNTAX Score

Calculate the SYNTAX score to determine the urgency and strength of CABG recommendation. 1, 2

High Complexity (SYNTAX Score >22):

• CABG is mandatory and PCI should not be performed. 1, 4
• At 5 years, CABG vs PCI results in: all-cause death 9.2% vs 14.6% (P = 0.006), MI 4.0% vs 9.2% (P = 0.001), and repeat revascularization 12.6% vs 25.4% (P < 0.001). 4
• The European Society of Cardiology provides Class I, Level A evidence that CABG is the overall preferred revascularization mode over PCI in complex disease. 1

Low Complexity (SYNTAX Score ≤22):

• PCI becomes an acceptable alternative only if complete revascularization can be achieved equivalent to CABG. 1, 4
• However, even in low SYNTAX scores, PCI results in significantly higher repeat revascularization (25.4% vs 12.6%, P = 0.038). 4

Left Ventricular Function Considerations

Assess left ventricular ejection fraction (LVEF) as it amplifies the survival benefit of CABG. 1, 5

• For LVEF 35-50%: CABG is reasonable to improve survival when viable myocardium is present (Class IIa, Level B). 1
• For LVEF <35%: CABG might be considered even without documented viability (Class IIb, Level B). 1
• In patients with triple vessel disease and LV dysfunction, CABG demonstrates lower cardiac death (HR 0.47,95% CI 0.25-0.91, P = 0.03) and MACCE (HR 0.63,95% CI 0.43-0.93, P = 0.02) compared to PCI. 6

Previous Myocardial Infarction: Timing Considerations

Critical timing pitfall: Avoid CABG within 3-7 days of acute MI unless there is ongoing ischemia with hemodynamic compromise, as surgical mortality is elevated during this window. 5

• If the previous MI occurred >7 days ago and the patient is stable, proceed with CABG evaluation. 5
• If the patient has life-threatening ventricular arrhythmias in the presence of triple vessel disease, emergency CABG is indicated (Class I). 5

Comorbidity Assessment: Surgical Risk

Evaluate surgical risk using the Society of Thoracic Surgeons (STS) predicted risk of operative mortality. 1

• If STS-predicted mortality >5%, severe COPD, disability from previous stroke, or previous cardiac surgery exists, PCI may be considered only if SYNTAX score ≤22. 1
• However, age alone should not be used to withhold CABG, as the benefit-to-risk ratio remains favorable when surgical risk is acceptable. 5

Surgical Technique Requirements

When CABG is performed, specific conduit selection is mandatory for optimal outcomes. 2, 5

• Use LIMA to LAD in every CABG procedure (long-term patency >90% at 10 years). 2, 5
• Use radial artery as the second conduit in preference to saphenous vein for the second most important target vessel. 2
• Complete revascularization is independently associated with significant reduction in MACCE (5-year freedom from MACCE: 72.5% vs 66.7% for incomplete revascularization). 2

Common Pitfalls to Avoid

Do not defer CABG in asymptomatic or mildly symptomatic patients with triple vessel disease—the survival benefit exists regardless of symptom severity. 7, 5

• The Class I indication for CABG in triple vessel disease is based on survival benefit, not symptom relief. 1

Do not perform PCI expecting equivalent outcomes to CABG in diabetic patients with triple vessel disease. 7

• The diabetes-CABG interaction shows substantially amplified mortality benefit (HR 2.30 for PCI vs CABG in diabetics compared to HR 1.51 in non-diabetics). 4

Do not use controlled hypothyroidism as a contraindication to CABG—it is not a surgical contraindication when optimized on medication. 2

Heart Team Discussion

A multidisciplinary Heart Team discussion is recommended to select the most appropriate revascularization modality. 1, 2

• Consider patient profile, coronary anatomy, procedural factors, LVEF, and patient preferences. 1, 2
• However, in this specific case (diabetes + triple vessel disease + previous MI + multiple comorbidities), the evidence overwhelmingly supports CABG as the standard of care. 1, 3, 8