30
Treatment
Table 12. Revascularization to Improve Survival Compared
with Medical Therapy
Anatomic Setting COR LOE
Unprotected Left Main (UPLM) or complex CAD
CABG and PCI I—Heart Team approach recommended C
CABG and PCI IIa—Calculation of STS and SYNTAX scores B
UPLM
CABG I B
PCI IIa—For SIHD when both of the following are present:
• Anatomic conditions associated with a low risk of
PCI procedural complications and a high likelihood
of good long-term outcome (eg, a low SYNTAX
score of ≤22, ostial or trunk left main CAD)
• Clinical characteristics that predict a significantly
increased risk of adverse surgical outcomes (eg,
STS-predicted risk of operative mortality ≥5%)
B
IIa—For UA/NSTEMI if not a CABG candidate B
IIa—For STEMI when distal coronary flow is TIMI
flow grade <3 and PCI can be performed more
rapidly and safely than CABG
C
IIb—For SIHD when both of the following are present:
• Anatomic conditions associated with a low to
intermediate risk of PCI procedural complications
and an intermediate to high likelihood of good long-
term outcome (eg, low-intermediate SYNTAX score
of <33, bifurcation left main CAD)
• Clinical characteristics that predict an increased risk
of adverse surgical outcomes (eg, moderate-severe
COPD, disability from prior stroke, or prior cardiac
surgery; STS-predicted operative mortality >2%)
B
III: Harm—For SIHD in patients (versus performing
CABG) with unfavorable anatomy for PCI and
who are good candidates for CABG
B
3-vessel disease with or without proximal LAD artery disease*
CABG I B
IIa—It is reasonable to choose CABG over PCI in
patients with complex 3-vessel CAD (eg, SYNTAX
score >22) who are good candidates for CABG
B
PCI IIb—Of uncertain benefit B
2-vessel disease with proximal LAD artery disease*
CABG I B
PCI IIb—Of uncertain benefit B
2-vessel disease without proximal LAD artery disease
CABG IIa—With extensive ischemia B
IIb—Of uncertain benefit without extensive ischemia C
PCI IIb—Of uncertain benefit B
