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  • Review Article
  • Published:

Optimal revascularization for complex coronary artery disease

Nature Reviews Cardiology volume 10, pages 635–647 (2013)Cite this article

Subjects

Key Points

  • The choice of revascularization strategy for patients with complex coronary artery disease (CAD) impacts patients' prognosis and quality of life, but the optimal strategy remains controversial

  • Percutaneous coronary intervention (PCI) or CABG surgery can be offered to patients with multivessel CAD and SYNTAX score ≤22, and those with left main stem disease and SYNTAX score ≤32

  • CABG surgery should remain the standard therapy for patients with complex CAD, especially those with diabetes mellitus or left ventricular systolic dysfunction

  • Follow-up duration should be considered when comparing PCI with CABG surgery; some studies show a survival benefit over PCI at 5 years follow-up, which was not apparent at <3 years

  • Multiple risk-stratification tools are available to help decision making; the role of the heart team is vital

Abstract

Patients with major or symptomatic coronary artery disease (CAD) commonly undergo revascularization—either with CABG surgery, which has been the mainstay of revascularization for more than half a century, or with percutaneous coronary intervention (PCI), which has become the more-commonly used strategy in the past decade. PCI has been tested in more randomized clinical trials than any other procedure in contemporary practice. In general, PCI is the preferred option for treating patients with simple coronary artery lesions and CABG surgery remains the standard of care for patients with complex CAD. Technical advancements in PCI and CABG surgery make comparisons of historical data for these strategies difficult. In this Review, we evaluate the evidence-based use of PCI and CABG surgery in treating patients with multivessel and unprotected left main stem disease and for specific patient groups, including those with diabetes mellitus, chronic heart failure, or chronic kidney disease. Finally, we highlight the available tools to aid decision-making, including clinical guidelines, risk scoring systems, and the role of the 'heart team'.

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Figure 1: A potential revascularization pathway for patients with stable angina pectoris.
Figure 2: Meta-analysis of randomized clinical trials in which CABG surgery was compared with percutaneous coronary intervention using drug-eluting stents for unprotected left main stem coronary artery disease.
Figure 3: A pragmatic approach for the use of risk stratification models for patients with CAD.
Figure 4: Key factors in decision-making for revascularization strategy.

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Acknowledgements

J. Iqbal is supported by National Institute of Health Research (NIHR), UK and a Fellowship from European Society of Cardiology.

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Authors and Affiliations

  1. Department of Cardiovascular Science, University of Sheffield, Medical School, Beech Hill Road, Sheffield, S10 2RX, UK

    Javaid Iqbal

  2. Department of Interventional Cardiology, Thorax Centre, Rotterdam, 3015 CE, Netherlands

    Patrick W. Serruys

  3. Department of Cardiothoracic Surgery, University of Oxford, Oxford, OX3 9DU, UK

    David P. Taggart

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  1. Javaid Iqbal
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  2. Patrick W. Serruys
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  3. David P. Taggart
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Contributions

J. Iqbal researched data, made substantial contribution to discussion of the content, and wrote the article. P. W. Serruys and D. P. Taggart made substantial contribution to discussion of the content, and reviewed and edited the manuscript before submission.

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Correspondence to David P. Taggart.

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The authors declare no competing financial interests.

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Iqbal, J., Serruys, P. & Taggart, D. Optimal revascularization for complex coronary artery disease. Nat Rev Cardiol 10, 635–647 (2013). https://doi.org/10.1038/nrcardio.2013.138

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