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target="_blank" rel="nofollow" href="#ulink_e264a0a1-2156-53c4-90ff-40b27c04f4dd">Table 11.3 ESC guidelines for the type of revascularization (CABG or PCI) in patients with stable CAD with suitable coronary anatomy for both procedures and low predicted surgical mortality.^d

      Source: Data from Neumann et al. 2019 [6].

Recommendations according to the extent of CAD	CABG	PCI
Classa	Levelb	Classa	Levelb
One‐ or two‐vessel disease without proximal LAD stenosis	IIb	C	I	C
One‐vessel disease with proximal LAD stenosis	I	A	I	A
Two‐vessel disease with proximal LAD stenosis	I	B	I	C
Left main disease with a SYNTAX score ≤ 22	I	A	I	A
Left main disease with a SYNTAX score 23–32	I	A	IIa	A
Left main disease with a SYNTAX score > 32c	I	A	III	B
Three‐vessel disease with a SYNTAX score ≤ 22	I	A	I	A
Three‐vessel disease with a SYNTAX score >22c	I	A	III	A
Three‐vessel disease with diabetes and SYNTAX score ≤ 22	I	A	IIb	A
Three‐vessel disease with diabetes and SYNTAX score >22c	I	A	III	A

      ^a Class of recommendation.

      ^b Level of evidence.

      ^c PCI should be considered if the Heart Team is concerned about the surgical risk or if the patient refuses CABG after adequate counselling by the Heart Team.

      ^d For example, absence of previous cardiac surgery, severe morbidities, frailty, or immobility precluding CABG.

Indications for coronary angiography

The decision regarding whether to treat a patient with medical therapy or revascularization is based on the fundamental principal of risk stratification. The spectrum of risk for myocardial infarction and cardiovascular death is wide even in stable CAD. Initial risk stratification and thereby the decision to perform coronary angiography can be determined by a combination of clinical evaluation, and in most cases stress testing and an assessment of left LV function (Figure 11.2). Those with high risk features on clinical evaluation such as severe angina, unstable angina, and severe heart failure should proceed directly to coronary angiography without being subjected to a stress test. Invasive coronary angiography is not indicated in low risk patients, however coronary CTA may be useful if imaging is desirable (Figure 11.3). The decision to perform non‐invasive testing in intermediate risk patients should be based on severity of symptoms, response to initial medical therapy, functional status, lifestyle, and occupation. Moreover, a detailed discussion with the patient regarding the risks, benefits, alternatives, and goals of invasive assessment is required prior to proceeding with coronary angiography. Coronary angiography is indicated in patients with high risk features on non‐invasive assessment irrespective of symptoms, severe angina (Class 3 of Canadian Cardiovascular Society Classification; CCS), limiting angina despite optimal medical therapy, diagnostic uncertainty after non‐invasive evaluation, and patients with the possibility of restenosis following PCI in a coronary distribution supplying a moderate to large amount of myocardium.

Figure 11.2 Approach for the initial diagnostic management of patients with angina and suspected coronary artery disease. ACS, acute coronary syndrome; BP, blood pressure; CAD, coronary artery disease; CTA, computed tomography angiography; ECG, electrocardiogram; FFR, fractional flow reserve; iFR, instantaneous wave‐free ratio; LVEF, left ventricular ejection fraction. ^aIf the diagnosis of CAD is uncertain, establishing a diagnosis using non‐invasive functional imaging for myocardial ischaemia before treatment may be reasonable. ^bMay be omitted in very young and healthy patients with a high suspicion of an extracardiac cause of chest pain, and in multimorbid patients in whom the echocardiography result has no consequence for further patient management. ^cConsider exercise ECG to assess symptoms, arrhythmias, exercise tolerance, BP response, and event risk in selected patients. ^dAbility to exercise, individual test‐related risks, and likelihood of obtaining diagnostic test result. ^eHigh clinical likelihood and symptoms inadequately responding to medical treatment, high event risk based on clinical evaluation (such as ST‐segment depression, combined with symptoms at a low workload or systolic dysfunction indicating CAD), or uncertain diagnosis on non‐invasive testing. ^fFunctional imaging for myocardial ischaemia if coronary CTA has shown CAD of uncertain grade or is non‐diagnostic. ^gConsider also angina without obstructive disease in the epicardial coronary arteries.

      Source: Knuuti et al 2020 [4]. Reproduced by permission of Oxford University Press.

Figure 11.3 Main diagnostic pathways in symptomatic patients with suspected obstructive CAD. Depending on clinical conditions and the healthcare environment, patient workup can start with either of three options: non‐invasive testing, coronary CTA, or invasive coronary angiography. Through each pathway, both functional and anatomical information is gathered to inform an appropriate diagnostic and therapeutic strategy. Risk‐factor modification should be considered in all patients. CAD, coronary artery disease; CTA, computed tomography angiography; ECG, electrocardiogram; LV, left ventricular. ^aConsider microvascular angina. ^bAntianginal medications and/or risk‐factor modification.

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