CAD treatment

From: Up to date

RECOMMENDATIONS — Among patients with stable angina, the goals of medical therapy or revascularization are to delay or prevent the complications of coronary disease in an effort to prolong life, decrease cardiac morbidity, and alleviate symptoms.
Recommendations for revascularization in patients with acute coronary syndromes are found elsewhere. (See "Selecting a reperfusion strategy for acute ST elevation myocardial infarction" and "Coronary arteriography and revascularization for unstable angina or non-ST elevation acute myocardial infarction".)

Revascularization with either coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) is indicated the following groups of patients with stable angina pectoris:
Patients with activity-limiting symptoms despite maximum medical therapy
Active patients who want PCI for improved quality of life compared to medical therapy
Those with anatomy for which revascularization has a proven survival benefit. (See 'Indications for revascularization' above.)

The combined outcome of death, myocardial infarction (MI), and stroke appears similar in such patients managed with either CABG or PCI. However, revascularization rates are higher with PCI. In those patients who receive PCI, outcomes vary with the complexity of the anatomy; those patients with more complex disease have worse outcomes than those with less complex disease. (See 'CABG versus PCI' above.)

For patients who require revascularization, available data suggests that most patients with one or two vessel disease are best managed with PCI, while those with multivessel or left main disease associated with impaired left ventricular systolic function are best managed with CABG. For patients who fall into neither of these categories, it is uncertain which procedure is preferable. We suggest that patients be informed in detail about the strengths and weaknesses of each procedure, including information about local expertise; shared decision making is extremely important in these patients. (See 'Special circumstances' above.)
Our recommendations below for patients with stable angina pectoris assume that local expertise is satisfactory for both PCI and CABG.
We recommend PCI, if technically feasible, as opposed to CABG, for patients with one or two vessel disease (Grade 1A). (See 'Single vessel CAD' above.)
We suggest CABG, as opposed to PCI, for patients with unprotected left main coronary artery disease who are reasonable surgical candidates (Grade 2B). (See "Management of left main coronary artery disease", section on 'Stents versus CABG'.)
We recommend CABG, as opposed to PCI, in patients with three vessel coronary artery disease and an LVEF <30 class="gradeLink" href="http://www.uptodate.com/online/content/grade.do?gradeId=3&title=Grade+1C" jquery1291584172386="45">Grade 1C). (See 'Patients in whom CABG might be preferred' above.)
We suggest revascularization with CABG, as opposed to PCI, for patients with multivessel coronary artery disease and relatively well preserved left ventricular systolic function (Grade 2B). This last recommendation assumes a preference by patients for a lower likelihood of having to return for repeat revascularization. For those patients who are less concerned with repeat revascularization but more concerned about the risk of stroke, PCI is a reasonable option. (See 'Drug-eluting stents' above.)
In addition to revascularization in appropriately selected patients, optimal treatment of patients with CAD should also focus on risk factor reduction. This includes low-dose aspirin, reaching treatment goals for hypertension and serum lipids, avoidance of smoking, controlling the serum glucose in patients with diabetes, and referral to a cardiac rehabilitation program. (See "Secondary prevention of cardiovascular disease: Risk factor reduction" and "Intensity of lipid lowering therapy in secondary prevention of coronary heart disease" and "Blood pressure management in patients with atherosclerotic cardiovascular disease" and "Efficacy of cardiac rehabilitation in patients with coronary heart disease".)