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Stable Ischemic Heart Disease

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33 Î(Updated in 2014) CABG is generally recommended in preference to PCI to improve survival in patients with diabetes mellitus and multivessel CAD for which revascularization is likely to improve survival (3-vessel CAD or complex 2-vessel CAD involving the proximal LAD), particularly if a LIMA graft can be anastomosed to the LAD artery, provided the patient is a good candidate for surgery. (I-B) Î CABG (I-B) or PCI (I-C) to improve survival is beneficial in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant (≥70% diameter) stenosis in a major coronary artery. Î (New in 2014) A Heart Team approach to revascularization is recommended in patients with diabetes mellitus and complex multivessel CAD. (I-C) Î CABG to improve survival is reasonable in patients with significant (≥70% diameter) stenoses in 2 major coronary arteries with severe or extensive myocardial ischemia (eg, high-risk criteria on stress testing, abnormal intracoronary hemodynamic evaluation, or >20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium. (IIa-B) Î CABG to improve survival is reasonable in patients with mild– moderate LV systolic dysfunction (EF 35%-50%) and significant (≥70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization. (IIa-B) Î CABG with a left internal mammary artery (LIMA) graft to improve survival is reasonable in patients with significant (≥70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia. (IIa-B) Î It is reasonable to choose CABG over PCI to improve survival in patients with complex 3-vessel CAD (eg, SYNTAX score >22), with or without involvement of the proximal LAD artery who are good candidates for CABG. (IIa-B) Î The usefulness of CABG to improve survival is uncertain in patients with significant (70%) diameter stenoses in 2 major coronary arteries not involving the proximal LAD artery and without extensive ischemia. (IIb-C) Î The usefulness of PCI to improve survival is uncertain in patients with 2- or 3-vessel CAD (with or without involvement of the proximal LAD artery) or 1-vessel proximal LAD disease. (IIb-B)

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