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Treatment
Revascularization to Improve Survival
Left Main CAD Revascularization
Î Coronary artery bypass graft (CABG) to improve survival is
recommended for patients with significant (≥50% diameter stenosis)
left main coronary artery stenosis. (I-B)
Î Percutaneous coronary intervention (PCI) to improve survival is
reasonable as an alternative to CABG in selected stable patients with
significant (≥50% diameter stenosis) unprotected left main CAD with:
(IIa-B)
• 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
[≤22], ostial or trunk left main CAD); and
• Clinical characteristics that predict a significantly increased risk of adverse surgical
outcomes (eg, STS-predicted risk of operative mortality ≥5%).
Î PCI to improve survival is reasonable in patients with unstable
angina/non–ST-elevation myocardial infarction (UA/NSTEMI) when
an unprotected left main coronary artery is the culprit lesion and the
patient is not a candidate for CABG. (IIa-B)
Î PCI to improve survival is reasonable in patients with acute ST-
elevation myocardial infarction (STEMI) when an unprotected left main
coronary artery is the culprit lesion, distal coronary flow is less than
TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be
performed more rapidly and safely than CABG. (IIa-C)
Î PCI to improve survival may be reasonable as an alternative to CABG
in selected stable patients with significant (≥50% diameter stenosis)
unprotected left main CAD with: (IIb-B)
• 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); and
• clinical characteristics that predict an increased risk of adverse surgical outcomes
(eg, moderate-severe chronic obstructive pulmonary disease, disability from
previous stroke, or previous cardiac surgery; STS-predicted risk of operative
mortality >2%).
Î PCI to improve survival should NOT be performed in stable patients
with significant (≥50% diameter stenosis) unprotected left main CAD
who have unfavorable anatomy for PCI and who are good candidates
for CABG. (III-B: Harm)
Non–Left Main CAD Revascularization
Î CABG to improve survival is beneficial in patients with significant
(≥70% diameter) stenoses in 3 major coronary arteries (with or
without involvement of the proximal left anterior descending [LAD]
artery) or in the proximal LAD artery plus 1 other major coronary
artery. (I-B)
