Revascularization

• OMT should be initial focus if stable & w/o evidence of critical anatomy & w/ normal EF
• Goal of revasc should be to ↓ risk of CV morbidity & mortality or to relieve refractory sx
• Older studies: survival benefit w/ revascularization (CABG) vs. medical Rx (pre-statin era) if: left main disease (≥50% stenosis); 3VD (≥70% stenoses) especially if ↓ EF, 2VD w/ critical proximal LAD, DM, ? 1–2 VD w/ large area of viable, ischemic myocardium
• More recent studies: revascularization (largely if not exclusively PCI) vs. OMT did not Δ risk of death, ↑ peri-PCI MI, and ± ↓ spontaneous MI (NEJM 2007;356:1503 & 2020;382:1395)
• In the most recent trial (ISCHEMIA, NEJM 2020;382:1395), which enrolled Pts w/ moderate-severe ischemia by noninvasive testing w/o LM disease and w/ preserved LVEF, revasc (~¾ PCI, ~¼ CABG) ↑ 5-yr rate of peri-procedural MI by ~2% and ↓ 5-yr rate of spontaneous MI by 3%. Nonsignificant ~1% lower rate of CV death by 5 yrs that appeared to start to emerge after 2 yrs. Magnitude of benefit tended to be greater in those with multivessel disease, proximal LAD disease, or diabetes.
• In Pts w/ CAD, HF, & LVEF <35%, CABG compared w/ medical Rx ↓ mortality by 16% and ↓ CV mortality by 21% after a median of 10 yrs (STICHES, NEJM 2016;374:1511)
• Thus, recommendations (Circ 2012;126:e354 & EHJ 2019;40:87) for revascularization include: Indicated in: ≥50% left main stenosis, 3VD (≥70% stenoses), 2VD w/ proximal LAD, unacceptable angina despite OMT Reasonable if: 2VD + extensive myocardial ischemia, MVD or proximal LAD disease + ↓ EF, proximal LAD disease + extensive ischemia, MVD + diabetes (if can get CABG)
• Trials of PCI vs. CABG in Pts w/ MVD or LM disease have shown CABG ↓ risk of spontaneous MI, repeat revascularization, ± death. These benefits appear greater in those with more complex coronary anatomy or with diabetes (Lancet 2018;391:939 & 2021;398:2247).