Sandbox: CR

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Revascularization to Improve Survival Compared With Medical Therapy (DO NOT EDIT)

Anatomic Setting	COR	LOE
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: 1) Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score of ≤ 22, ostial or trunk left main CAD) 2) Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality ≥ 5%)	B
PCI	IIa—For UA/NSTEMI if not a CABG candidate	B
PCI	IIa—For STEMI when distal coronary flow is TIMI flow grade <3 and PCI can be performed more rapidly and safely than CABG	C
PCI	IIb—For SIHD when both of the following are present:1) Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate SYNTAX score of <33, bifurcation left main CAD) 2) Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate—severe COPD, disability from prior stroke, or prior cardiac surgery; STS-predicted operative mortality >2%)	B
PCI	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 (e.g., 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
CABG	IIb—Of uncertain benefit without extensive ischemia	C
CABG	IIb—Of uncertain benefit	B
1-vessel proximal LAD artery disease
CABG	IIa—With LIMA for long-term benefit	B
PCI	IIb—With LIMA for long-term benefit	B
	1-vessel proximal LAD artery disease
CABG	III: Harm	B
PCI	III: Harm	B
LV dysfunction
CABG	IIa—EF 35% to 50%	B
CABG	IIb—EF <35% without significant left main CAD	B
PCI	Insufficient data
Survivors of sudden cardiac death with presumed ischemia-mediated VT
CABG	I	B
PCI	I	C
No anatomic or physiological criteria for revascularization
CABG	III: Harm	B
PCI	III: Harm	B
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not available; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; UPLM, unprotected left main disease; and VT, ventricular tachycardia.

Noninvasive Risk Stratification

High risk (>3% annual death or MI) 1. Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes 2. Resting perfusion abnormalities $10% of the myocardium in patients without prior history or evidence of MI 3. Stress ECG findings including $2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/VF 4. Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress $10%) 5. Stress-induced perfusion abnormalities encumbering $10% myocardium or stress segmental scores indicating multiple vascular territories with abnormalities 6. Stress-induced LV dilation 7. Inducible wall motion abnormality (involving >2 segments or 2 coronary beds) 8. Wall motion abnormality developing at low dose of dobutamine (#10 mg/kg/min) or at a low heart rate (<120 beats/min) 9. CAC score >400 Agatston units 10. Multivessel obstructive CAD ($70% stenosis) or left main stenosis ($50% stenosis) on CCTA

Intermediate risk (1% to 3% annual death or MI) 1. Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes 2. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI 3. $1 mm of ST-segment depression occurring with exertional symptoms 4. Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular territory with abnormalities but without LV dilation 5. Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed 6. CAC score 100 to 399 Agatston units 7. One vessel CAD with $70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in $2 arteries on CCTA

Low risk (<1% annual death or MI) 1. Low-risk treadmill score (score $5) or no new ST segment changes or exercise-induced chest pain symptoms; when achieving maximal levels of exercise 2. Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium* 3. Normal stress or no change of limited resting wall motion abnormalities during stress 4. CAC score <100 Agaston units 5. No coronary stenosis >50% on CCTA

CAC indicates coronary artery calcium; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; LV, left ventricular; LVEF, left ventricular ejection fraction; and MI, myocardial infarction.