Guideline–Practice Mismatch in Coronary Revascularization at Hospitals Without On-Site Cardiac Surgery: A SYNTAX II and EuroSCORE II–Based Real-World Analysis

Background Current international guidelines strongly recommend Heart Team–based decision-making using integrated anatomical and clinical risk scores, including SYNTAX II and EuroSCORE II, to guide selection between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease. However, real-world adherence to these recommendations in centers without on-site cardiac surgery remains insufficiently studied. Objectives To retrospectively evaluate real-world concordance between SYNTAX II– and EuroSCORE II–derived revascularization recommendations and actual treatment decisions in a tertiary hospital without on-site cardiac surgery, and to identify predictors of guideline discordance. Methods We conducted a retrospective, single-center analysis of 270 consecutive patients evaluated for coronary revascularization between 2023 and 2024. SYNTAX II and EuroSCORE II were calculated retrospectively by two experienced interventional cardiologists blinded to treatment decisions. Guideline-based recommendations (PCI, CABG, or either) were compared with the revascularization strategy performed in practice. Predictors of discordance were assessed using univariable logistic regression. Results Overall concordance between guideline-derived recommendations and real-world management was highly asymmetric. Concordance was high when SYNTAX II favored PCI (81%), but markedly low when CABG was recommended (16%). A CABG recommendation was the sole independent predictor of discordance, conferring a >20-fold increased likelihood of deviation from guideline-based management (OR ≈23, p<0.001). Notably, age, frailty score, left ventricular function, renal function, EuroSCORE II, and major cardiovascular risk factors were not associated with discordance. Conclusions In hospitals without on-site cardiac surgery, guideline-recommended CABG strategies are frequently not implemented, independent of patient risk or anatomical complexity. This systematic deviation reflects institutional and structural constraints rather than patient-level clinical judgment, revealing a critical implementation gap in contemporary revascularization care. These findings highlight the urgent need for adaptive Heart Team models, inter-institutional pathways, or guideline frameworks that explicitly account for institutional capabilities.