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Stable Ischemic Heart Disease

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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

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