Why the study?
Optimal revascularization strategies for patients with stable ischemic heart disease and varying coronary anatomies remain uncertain, necessitating guideline recommendations.
Does PCI or CABG provide better outcomes in patients with stable ischemic heart disease across different coronary anatomies?
Does PCI or CABG provide better outcomes in patients with stable ischemic heart disease across different coronary anatomies?
Answers are grounded in this paper and cite their sources.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We are pleased to learn BRILINTA has been included in revised guidelines issued by AHA, ACCF and SCAI. The addition to yet another set of important clinical guidelines highlights the value BRILINTA can bring to patients with ACS and health care professionals trying to reduce the rate of thrombotic cardiovascular events and the momentum this important treatment option is gaining just four months after FDA approval.”
“The new guidelines issued by the ACCF and AHA recognize Effient as an important treatment option for the population of ACS patients who receive PCI with or without a stent after experiencing unstable angina or NSTEMI, which is a type of heart attack that that does not need to be treated with emergent opening of a blocked coronary artery. This updated clinical guidance offers alternative treatment options for cardiologists when they are considering appropriate oral antiplatelet therapy for patients with different forms of ACS.”
“The latest guidelines recommend additional use of IVUS and FFR, both of which represent key product lines in Volcano's broad portfolio of precision guided technologies, in patients undergoing PCI. These recommendations confirm the positive role that IVUS and FFR technologies play in the care of PCI patients.”
This guideline provides anatomical and clinical criteria to guide the choice between PCI and CABG in patients with stable ischemic heart disease.
III: Harm-For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG B 13,17,19,24-32 3-vessel disease with or without proximal LAD artery disease* CABG I B 26,30,53-56 IIa-It is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD (eg, SYNTAX score Ͼ22) who are good candidates for CABG B 32,46,56,71,72 PCI IIb-Of uncertain benefit B 26,46,53,56,82 2-vessel disease with proximal LAD artery disease* CABG I B 26,30,53-56 PCI IIb-Of uncertain benefit B 26,53,56,82 2-vessel disease without proximal LAD artery disease* CABG IIa-With extensive ischemia B 60-63 IIb-Of uncertain benefit without extensive ischemia C 56 PCI IIb-Of uncertain benefit B 26,53,56,82 1-vessel proximal LAD artery disease CABG IIa-With LIMA for long-term benefit B 30,56,69,70 PCI IIb-Of uncertain benefit B 26,53,56,82 1-vessel disease without proximal LAD artery involvement CABG III: Harm B 30,53,60,61,94-98 PCI III: Harm B 30,53,60,61,94-98 LV dysfunction CABG IIa-EF 35% to 50% B 30,64-68 CABG IIb-EF Ͻ35% without significant left main CAD B 30,64-68,83,84 PCI Insufficient data N/A Survivors of sudden cardiac death with presumed ischemia-mediated VT CABG I B 57-59 PCI I C 5 7 No anatomic or physiologic criteria for revascularization CABG III: Harm B 30,53,60,61,94-98 PCI III: Harm B 30,53,60,61,94-98 *In patients with multivessel disease who also have diabetes, it is reasonable to choose CABG (with LIMA) over PCI 62,74 -81 (Class IIa; LOE: B).CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not applicable; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TIMI, Thrombolysis in Myocardial Infarction; UA/NSTEMI, unstable angina/non-ST-elevation myocardial infarction; UPLM, unprotected left main disease; and VT, ventricular tachycardia.
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Levine et al. (2011) conducted a review in Coronary artery disease. Percutaneous Coronary Intervention vs. Coronary Artery Bypass Graft was evaluated. The 2011 ACCF/AHA/SCAI guidelines provide evidence-based recommendations for selecting between CABG and PCI across various anatomical complexities of coronary artery disease.
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