‘Ten Commandments’ for the 2018 ESC/EACTS Guidelines on Myocardial Revascularization

The 2018 ESC/EACTS Guidelines on Myocardial Revascularization were developed by a joint effort of the European Society of Cardiology (ESC) and the European Association of Cardiovascular Surgery (EACTS). The guidelines are intended to support clinical practice by pragmatic recommendations that are based on the body of evidence available at the time of writing and on professional experience where evidence is missing. For this purpose, the ESC and the EACTS assembled a joint Task Force of interventional cardiologists, cardiac surgeons, and non-interventional cardiologists. The Task Force built on the 2010 and 2014 versions of the Guidelines on Myocardial Revascularization and reviewed more recent high-quality data from clinical trials and meta-analyses. The new guidelines underwent extensive independent review pointing out areas of uncertainty or controversy due to inconclusive evidence. The Task Force carefully appraised this input. When revisiting recommendations of previous guidelines, it was decided to take a cautious conservative position. Thus, previous recommendations remained unchanged unless amendment was mandated by robust new evidence. To be able to present a document that covers all aspects of myocardial revascularization, overlap with other ESC Guidelines was tolerated and previous recommendations were kept, unless new evidence necessitated revision. Both, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), are highly efficient in alleviating symptoms of myocardial ischaemia and both are capable of improving prognosis. There remains a gap between PCI and CABG, with PCI being associated with faster recovery and lower risk of early events, including stroke, and CABG being associated with improved survival and reduced risk of spontaneous myocardial infarction and repeat intervention in the long run. The difference in the risk of recurrent ischaemic events, favouring CABG, mainly depends on the complexity of coronary artery disease and the presence of diabetes mellitus. Thus, the difference in long-term outcomes between CABG and PCI is negligible with low complexity coronary artery disease, but substantial with high complexity, especially when combined with diabetes. The guidelines suggest evidence-based criteria that inform individual treatment decisions and facilitate a reasonable selection of the optimal revascularization strategy to be offered to the patient. The choice of the revascularization method is a shared decision, involving the patient informed by the heart team of the early and long-term benefits and risks of the recommended revascularization strategy and its alternative. The Ten Commandments (1) Objective evidence of myocardial ischaemia by non-invasive stress imaging and/or intravascular assessment of the functional relevance of coronary artery stenoses are needed to indicate myocardial revascularization through PCI or CABG and to select the appropriate targets for PCI. (2) With large areas of inducible myocardial ischaemia or relevant left ventricular systolic dysfunction myocardial revascularization through CABG or PCI is indicated to improve long-term survival. (3) Myocardial revascularization is also indicated for relief of symptoms of myocardial ischaemia despite medical therapy optimized with respect for patient preferences. (4) The prognostic and symptomatic benefit of myocardial revascularization critically depends on the completeness of revascularization. Therefore, the ability to achieve complete revascularization is a key issue when choosing the appropriate treatment modality. (5) Apart from issues of individual operative risk and technical feasibility, diabetes mellitus and anatomical complexity of coronary artery disease determine the relative benefits of PCI and CABG. Diabetes mellitus and extensive coronary artery disease are predictors of a long-term survival benefit of CABG. (6) The SYNTAX score is the recommended tool to gauge the anatomical complexity of coronary disease. (7) Complex cases call for the Heart Team to be consulted to develop individualized treatment concepts with respect for the preferences of the patient informed about early and late outcomes. (8) Radial access is preferred for any PCI irrespective of clinical presentation, unless there are overriding procedural considerations. (9) Drug eluting stents are recommended for any PCI irrespective of clinical presentation, lesion type, anticipated duration of dual antiplatelet therapy, or concomitant anticoagulant therapy. (10) Multiple arterial grafting should be performed using the radial artery for high-grade stenosis and/or bilateral internal mammary artery grafting for patients who do not have an increased risk for sternal wound infection. Conflict of interest: none declared.