Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- Thomas Levin, MD
Thomas Levin, MD
- Illinois Heart and Vascular
- Chicago, Illinois
- Julian M Aroesty, MD
Julian M Aroesty, MD
- Clinical Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Stephan Windecker, MD
Stephan Windecker, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Department of Cardiology
- Bern University Hospital
Patients with stable coronary artery disease should be assessed periodically to determine whether medical therapy or medical therapy with revascularization is a more appropriate strategy. (See "Stable ischemic heart disease: Indications for revascularization", section on 'Summary and recommendations'.)
This topic will present our approach to choosing between percutaneous coronary intervention (PCI) with stenting and coronary artery bypass graft surgery (CABG), the two principal options for revascularization. The recommended approach to choosing between CABG and PCI in patients with stable one, two, and three vessel disease who are candidates for intervention and who have an ejection fraction greater than about 35 to 40 percent will be reviewed here. Patients with ischemic cardiomyopathy, and who typically have a left ventricular ejection fraction ≤35 to 40 percent, are discussed separately. (See "Diagnosis and management of ischemic cardiomyopathy", section on 'PCI and comparison to CABG'.)
The approach to revascularization in patients with left main disease, acute coronary syndromes, or diabetes is discussed in separate topic reviews. (See "Management of left main coronary artery disease" and "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy" and "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction" and "Coronary artery revascularization in patients with diabetes mellitus and multivessel coronary artery disease".)
Regardless of which method of revascularization is used, aggressive risk-factor modification is necessary in all patients. (See "Prevention of cardiovascular disease events in those with established disease or at high risk" and "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease".)
INDICATIONS FOR REVASCULARIZATION
The decision to proceed with revascularization with either coronary artery bypass graft surgery or percutaneous coronary intervention (PCI), as opposed to continuing medical therapy, is made in three groups of stable patients:
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- INDICATIONS FOR REVASCULARIZATION
- LEFT MAIN CORONARY ARTERY DISEASE
- SINGLE VESSEL DISEASE
- TWO AND THREE VESSEL DISEASE
- Balloon angioplasty or BMS compared to CABG
- DES compared to CABG
- - Outcomes based on disease severity
- Hybrid coronary revascularization
- PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION
- PATIENTS WITH PREVIOUS CABG
- OUR APPROACH
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS