How should I decide on revascularisation for a patient with coronary artery disease based on acute coronary syndrome status, symptom burden, objective evidence of myocardial ischemia, coronary anatomy, and procedural risk?

How to Decide on Revascularization in Coronary Artery Disease

Base your revascularization decision on a hierarchical assessment: first determine if the patient has an acute coronary syndrome requiring urgent intervention, then evaluate the presence and severity of ischemia, followed by coronary anatomy complexity, and finally procedural risk—with high-risk ACS features, significant ischemia (>10% LV), or high-risk anatomy (left main, proximal LAD, or multivessel disease with reduced LVEF) mandating revascularization regardless of symptom burden. 1

Step 1: Determine Acute Coronary Syndrome Status

STEMI Patients

• Emergency revascularization is mandatory for all STEMI patients presenting within 12 hours of symptom onset to restore flow and reduce mortality. 2, 1
• Primary PCI is the preferred reperfusion strategy over fibrinolysis when deliverable within appropriate timeframes. 2
• In hemodynamically stable STEMI with multivessel disease, perform primary PCI of the culprit artery only, then staged PCI of significant non-infarct stenoses either in-hospital or within 45 days (Class I, Level A). 1
• Critical exception: In cardiogenic shock, do NOT routinely revascularize non-infarct arteries during primary PCI—this increases risk of death and renal failure (Class III: Harm). 2, 1

NSTE-ACS/Unstable Angina Patients

Proceed with early invasive strategy (<24 hours) if ANY of these high-risk features are present: 2

• Recurrent angina/ischemia at rest or with minimal activity despite intensive medical therapy
• Heart failure symptoms, S3 gallop, pulmonary edema, new/worsening mitral regurgitation
• Hemodynamic instability or hypotension with angina
• Sustained ventricular tachycardia
• Depressed LV systolic function (LVEF <40%)
• Prior PCI within 6 months or prior CABG
• Age >65 years with ST-segment depression or elevated cardiac markers

Invasive strategy within 72 hours is indicated for: 2

• Intermediate-risk features without the above high-risk criteria
• Recurrent symptoms despite initial stabilization

Do NOT perform angiography in: 2

• Patients with extensive comorbidities where revascularization risks outweigh benefits (liver failure, pulmonary failure)
• Patients unwilling to consent to revascularization
• Low likelihood of ACS with chest pain

Step 2: Assess Symptom Burden and Medical Therapy Response

Symptomatic Patients

• Revascularization is reasonable for stable angina refractory to maximal medical therapy, which should include β-blockers, calcium channel blockers, and nitrates (Class IIa, Level C). 1
• Any hemodynamically significant stenosis causing limiting angina with insufficient response to optimized medical therapy warrants revascularization. 2

Asymptomatic or Minimally Symptomatic Patients

• Revascularization based solely on angiographic stenosis without symptoms or ischemia documentation is NOT recommended—avoid the "oculostenotic reflex." 1
• Proceed to ischemia assessment before considering revascularization. 2

Step 3: Document Objective Evidence of Myocardial Ischemia

Functional assessment is essential for intermediate stenoses—revascularization targets ischemia, not anatomic stenosis alone. 2

Invasive Physiological Assessment

• FFR ≤0.80 or iwFR indicating hemodynamic significance should prompt revascularization due to increased risk of urgent readmission and need for target-vessel revascularization (Class I, Level A). 2, 1
• Do NOT revascularize coronary arteries with FFR >0.80 or <70% diameter stenosis of non-left main arteries with the primary intent to improve survival (Class III: Harm). 1

Noninvasive Ischemia Testing

• High-risk findings on noninvasive stress testing mandate early invasive strategy in NSTE-ACS patients. 2
• Large area of ischemia (>10% LV) on functional testing indicates need for revascularization for prognostic benefit. 2
• Low-risk noninvasive testing in asymptomatic patients does NOT warrant revascularization. 2

Step 4: Evaluate Coronary Anatomy

Anatomy Mandating Revascularization for Survival Benefit

Left Main Disease:

• CABG is recommended for left main stenosis >50% (Class I, Level A). 2, 1
• PCI is reasonable when it can provide equivalent revascularization to CABG (Class IIa). 1

Multivessel Disease with Reduced LVEF:

• CABG is recommended for 3-vessel disease, with greater survival benefit when LVEF <50% (Class I, Level A). 2
• CABG is recommended for 2-vessel disease with significant proximal LAD and LVEF <50% or demonstrable ischemia (Class I, Level A). 2
• In patients with severe LV systolic dysfunction (LVEF ≤35%) and suitable coronary disease, myocardial revascularization is recommended, with CABG as first choice. 2

Proximal LAD Involvement:

• Any proximal LAD stenosis >50% warrants revascularization for prognostic benefit. 2
• Both CABG and PCI are Class I recommendations for symptomatic proximal LAD stenosis inadequately responsive to medical therapy. 3

Single or Two-Vessel Disease:

• PCI or CABG for 1- or 2-vessel CAD with large area of viable myocardium and high-risk criteria on noninvasive testing (Class I, Level B). 2
• Do NOT revascularize 1- or 2-vessel CAD without significant proximal LAD in asymptomatic patients or those without ischemia on noninvasive testing (Class III). 2

Step 5: Choose Between PCI and CABG Based on Anatomy and Comorbidities

Calculate SYNTAX score to assess anatomic complexity and STS score to assess surgical risk. 2, 1

CABG is Preferred Over PCI When:

• Multivessel disease with diabetes mellitus, especially SYNTAX score >22. 3, 4
• Complex coronary anatomy with high SYNTAX score. 2
• LVEF 35-50% with multivessel disease or proximal LAD stenosis. 1, 3
• 3-vessel disease with acceptable surgical risk. 2

PCI is Preferred When:

• Single or double vessel disease with favorable morphology (non-ostial lesions, mid/distal LAD). 2
• Multivessel disease with normal LV function, no diabetes, and suitable anatomy (Class I, Level A). 2
• Patient cannot tolerate surgical risk or has prohibitive comorbidities. 2

Critical Contraindications:

• Do NOT perform PCI if patient cannot tolerate or comply with dual antiplatelet therapy for appropriate duration. 1
• Do NOT perform emergency CABG after failed PCI with no-reflow phenomenon—CABG is unlikely to improve perfusion and may cause harm. 1

Step 6: Assess Procedural Risk and Comorbidities

• Do NOT proceed with revascularization in patients with extensive comorbidities (liver failure, pulmonary failure) where risks clearly outweigh benefits (Class III, Level C). 2
• Use STS score to quantify in-hospital/30-day mortality and morbidity risk after CABG (Class I, Level B). 2
• In cardiogenic shock, emergency PCI is indicated if anatomy is amenable; emergency CABG is recommended if anatomy is not amenable to PCI. 2

Common Pitfalls to Avoid

• Never revascularize based solely on angiographic stenosis ≥70% in stable patients without physiological assessment or ischemia documentation—this is the "oculostenotic reflex" error. 1
• Do not routinely use thrombus aspiration in primary PCI—it is not recommended. 2
• Do not routinely use IABP in cardiogenic shock due to ACS—it is not recommended. 2
• Do not perform routine revascularization of non-culprit arteries during primary PCI in cardiogenic shock. 2, 1
• Do not order invasive angiography based solely on high coronary calcium score without symptoms or objective ischemia. 1, 5
• Do not withhold revascularization in high-risk anatomy (left main, 3-vessel disease with reduced LVEF) based on lack of symptoms—these patients derive survival benefit. 2