described, there is no documented survival advantage with revascularization. PCI and CABG should be offered for the treatment of symptoms refractory to medical therapy. The guidelines state that both forms of revascularization are suitable for two vessel disease, but in current practice the majority of these patients and those with single vessel disease are treated with PCI unless the lesions are angiographically unsuitable, or involve the proximal LAD [57].
Revascularization in asymptomatic patients should only be considered with the goal of improving prognosis. The guidelines for the treatment of asymptomatic patients are similar to those for symptomatic patients. However, the level of evidence for asymptomatic patients is weaker as the clinical trials have mainly included symptomatic patients. The presence and extent of inducible ischemia are important considerarions for guiding management in asymptomatic patients.
Conclusions
Unlike PCI for acute coronary syndromes, percutaneous revascularization does not prevent death or myocardial infarction in patients with stable angina. There remains the possibility that PCI can reduce these endpoints in high risk patients, but clinical trials in such patient subsets have not been conducted. For patients with lower risk, the main advantage of PCI is the ability to effectively and more rapidly relieve symptoms. In general, therefore, PCI is indicated for the treatment of symptomatic coronary atherosclerosis, particularly in patients who remain symptom limited despite optimal medical therapy. PCI is the preferred revascularization strategy for single vessel disease, younger patients (age <50 years), elderly patients with significant comorbid conditions, and those who are not surgical candidates. There is no clear indication for PCI in the treatment of asymptomatic disease.
CABG is also highly effective in relieving symptoms, but importantly it reduces mortality in high risk patients. This benefit is proportional to baseline risk profile of the patient. Complete revascularization is more likely to be achieved with CABG. Thus, CABG is preferred for high risk patients such as those with multivessel disease where complete revascularization is an important goal, particularly in three vessel disease, and in the presence of significant LV systolic dysfunction. Subgroups that should be considered for surgery include significant unprotected left main disease, three vessel disease, especially if there is impaired LV function, diffuse atherosclerosis, or one or more chronic total occlusion. An important group of patients who benefit with CABG are diabetics with three vessel disease. However, as with PCI, CABG does not reduce the incidence of non‐fatal myocardial infarction. PCI for multivessel disease, even with the use of first generation DES, is associated with higher rates of repeat revascularization than CABG.
Ongoing advances in medical therapy for secondary prevention, PCI and CABG result in limited data being available from clinical trials that reflect contemporary practice, especially in high risk patients. The FAME 3 trial (ClinicalTrials.gov Identifier: NCT02100722) will provide much needed data regarding the comparative efficacy of physiology guided PCI using second generation stents compared to CABG.
Interactive multiple choice questions are available for this chapter on www.wiley.com/go/dangas/cardiology
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