The 2022 review of left main coronary artery disease (LM CAD) management in the myocardial revascularization guidelines from the European Association for Cardio-Thoracic Surgery (EACTS) and the ESC (originally issued in 2018) downgraded percutaneous coronary intervention (PCI) for patients with LM CAD and low-to-intermediate SYNTAX score (0-32 points) to class IIa, while maintaining coronary surgery as class I.
The 2024 clinical guidelines by the ESC, endorsed by the EACTS, propose several adjustments that do not alter the established clinical superiority of coronary artery bypass grafting (CABG) over PCI or medical treatment for LM CAD:
Recommendations for Myocardial Revascularization in Chronic Coronary Syndrome Based on Anatomy and Clinical Presentation (ESC 2024 Clinical Practice Guidelines)
| Condition | Recommendation | Class |
| Left Main Coronary Artery Disease (LM CAD) | ||
| In patients with chronic coronary syndrome (CCS) and low surgical risk (e.g., no previous cardiac surgery, severe comorbidities, frailty, or immobility that would impede CABG) with LM CAD, coronary revascularization is recommended over medical treatment alone to improve survival. | I | A |
| Coronary artery bypass grafting is recommended as the preferred revascularization method over PCI, due to lower risk of spontaneous myocardial infarction and repeat revascularization. | I | A |
| In patients with CCS and LM CAD of low complexity (SYNTAX score ≤22) where PCI can provide complete revascularization equivalent to CABG, PCI is recommended as an alternative due to lower invasiveness and comparable survival. | I | A |
| In patients with CCS and LM CAD of intermediate complexity (SYNTAX score 23-32) where PCI can provide complete revascularization equivalent to CABG, PCI should be considered as an alternative due to lower invasiveness and comparable survival. | IIa | A |
| Left Main Coronary Artery Disease with Multivessel Disease (MVD) | ||
| In CCS patients with low surgical risk and suitable anatomy, CABG is recommended over medical treatment alone to improve survival. | I | A |
| In CCS patients with high surgical risk, PCI may be considered as an alternative to medical therapy alone. | IIb | B |
The 2024 ESC guidelines allocate significant attention to multivessel disease, proposing various treatment approaches based on the number of affected coronary arteries and the presence of diabetes:
Myocardial Revascularization Recommendations for Multivessel Disease and Diabetes
| Condition | Recommendation | Class |
| Multivessel Disease and Diabetes | ||
| In CCS patients with significant multivessel disease and diabetes who respond inadequately to guideline-recommended medical therapy, CABG is recommended over both medical therapy alone and PCI to improve symptoms and outcomes. | I | A |
| In CCS patients with extremely high surgical risk, PCI should be considered over medical therapy alone to alleviate symptoms and adverse outcomes. | IIa | B |
| Triple Vessel Disease without Diabetes | ||
| In CCS patients with significant triple vessel disease, preserved left ventricular ejection fraction (LVEF), and no diabetes who do not respond to guideline-recommended medical therapy, CABG is recommended over medical therapy alone to improve symptoms, survival, and other outcomes. | I | A |
| In CCS patients with preserved LVEF, no diabetes, and significant triple vessel disease of low-to-intermediate anatomical complexity where PCI can provide complete revascularization comparable to CABG, PCI is recommended due to its less invasive nature and generally non-inferior survival. | I | A |
| Single or Double Vessel Disease Involving the Proximal Left Anterior Descending (LAD) Artery | ||
| In CCS patients with significant single or double vessel disease involving the proximal LAD and inadequate response to guideline-recommended medical therapy, CABG or PCI is recommended over medical therapy alone to improve symptoms and outcomes. | I | A |
| In CCS patients with significant complex single or double vessel disease involving the proximal LAD, less amenable to PCI, and an inadequate response to medical therapy, CABG is recommended to alleviate symptoms and reduce revascularization rates. | I | B |
| Single or Double Vessel Disease Not Involving the Proximal LAD | ||
| In symptomatic CCS patients with significant single or double vessel disease not involving the proximal LAD and insufficient response to medical therapy, PCI is recommended to relieve symptoms. | I | B |
| In symptomatic CCS patients with significant single or double vessel disease not involving the proximal LAD, non-amenable to revascularization with PCI, CABG may be considered to improve symptoms. | IIb | C |
The 2024 ESC guidelines also detail revascularization recommendations for patients with left ventricular ejection fraction (LVEF) ≤35%:
Recommendations for Improving Outcomes in CCS Patients with LVEF ≤35%
| Condition | Recommendation | Class |
| In CCS patients with LVEF ≤35%, choosing between myocardial revascularization and medical treatment should follow careful assessment, ideally by the Heart Team, of coronary anatomy, the correlation between coronary disease and LV dysfunction, comorbidities, life expectancy, individual risk-benefit ratio, and patient perspectives. | I | C |
| In surgical candidates with multivessel coronary disease and LVEF ≤35%, CABG is recommended over medical therapy alone to improve long-term survival. | I | B |
| In selected CCS patients with multivessel coronary disease and LVEF ≤35% who have high surgical risk or are inoperable, PCI may be considered as an alternative to surgery. | IIb | B |
COMMENTARY:
The 2024 ESC clinical guidelines uphold CABG as a class I indication for LM CAD patients with acceptable surgical risk, given its survival benefits compared to medical therapy and its superior outcomes compared to PCI in terms of reducing spontaneous myocardial infarction and repeat revascularization.
PCI remains a class I indication for LM CAD patients of low complexity (SYNTAX score ≤22), while retaining class IIa status for intermediate complexity (SYNTAX score 23-32), provided that complete revascularization equivalent to CABG is achieved. In 2018, the ESC and EACTS guidelines classified high-complexity LM CAD (SYNTAX score ≥33) as class I for CABG and class III (not recommended) for PCI. However, the 2024 ESC guidelines do not include a class III indication for any treatment modality in chronic coronary syndrome.
For these guidelines, ESC authors drew primarily on the individual patient data meta-analysis by Sabatine et al. (2021), which analyzed data from four randomized clinical trials (RCTs): SYNTAX, PRECOMBAT, EXCEL, and NOBLE. This meta-analysis, covering 4,394 patients randomly assigned to either PCI with drug-eluting stents (n=2,197) or CABG (n=2,197), documented CABG’s superiority in 5-year risk reduction for spontaneous myocardial infarction (hazard ratio [HR]=2.35; 95% confidence interval [CI] 1.71-3.23; p<.0001) and repeat revascularization (HR=1.78; 95% CI 1.51-2.10; p<.0001), without a significant survival difference over 5 years (HR=1.10; 95% CI 0.91-1.32; p=.33).
The Sabatine et al. meta-analysis also provided results from a Bayesian analysis of overall mortality, suggesting a possible survival benefit for CABG over PCI, estimated at less than 0.2% per year. However, this finding was not considered robust enough by the 2024 ESC guideline authors to confirm a survival advantage for CABG over PCI.
As documented, the current ESC guidelines dedicate a specific section to patients with LM CAD associated with multivessel disease. This issue is critical, as the majority (53%) of patients with LM CAD in the previously mentioned RCTs (SYNTAX, PRECOMBAT, EXCEL, and NOBLE) also had multivessel disease. In fact, only 16% of the populations treated in these four RCTs had isolated LM CAD. This distribution is not surprising. The 2023 SWEDEHEART study, commented on in the guidelines, corroborates the survival and outcome benefits of CABG over PCI in a representative cohort from Sweden’s healthcare system, analyzing 11,137 patients with LM CAD treated with either CABG (n=9,364) or PCI (n=1,773) over an 11-year period. In the majority of this population (81%), LM CAD was associated with multivessel disease.
According to the 2024 ESC guidelines, for patients with LM CAD and multivessel disease, CABG retains a class I recommendation, while PCI holds a class IIb recommendation.
In general, recommendations for treating multivessel coronary artery disease without associated LM CAD continue to demonstrate the clinical superiority of surgical treatment. This superiority is most pronounced in patients with diabetes (CABG: class I; PCI: class IIa) and in patients with LVEF ≤35% (CABG: class I; PCI: class IIb). Notably, CABG maintains a class I recommendation (equivalent to PCI, provided it achieves complete revascularization) even in patients without diabetes. This contrasts with the 2021 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines, where the controversial interpretation of the ISCHEMIA trial downgraded CABG to a class IIb recommendation for multivessel disease treatment. The core evidence supporting CABG in multivessel disease patients is the 2018 individual patient data meta-analysis by Head et al., which analyzed outcomes across 11 RCTs. This study documented that in a 5-year mortality analysis for patients with multivessel disease treated surgically (n=3,520) or percutaneously (n=3,520), PCI was associated with a significantly higher mortality risk (mortality in the PCI group: 11.5%; mortality in the CABG group: 8.9%; HR=1.28; 95% CI 1.09–1.49; p=.0019).
The central role of CABG in patients with multivessel disease, particularly those with diabetes and left ventricular dysfunction, is further supported by the FREEDOM and STITCH trials, respectively.
In conclusion, the current ESC guidelines on chronic coronary syndrome management represent a major advancement toward sustained collaboration between European cardiology and cardiothoracic surgery societies. This collaboration enhances the balance observed in the recommendations formulated for various clinical entities. These guidelines reaffirm the superiority of CABG over both medical treatment and PCI for isolated LM CAD, LM CAD with multivessel disease, and isolated multivessel coronary artery disease, especially in patients with diabetes or LVEF ≤35%. Local Heart Teams’ failure to adhere to the evidence presented in these guidelines not only contradicts the cooperative approach promoted by the ESC and EACTS but also risks exposing CCS patients to unacceptably high rates of adverse cardiovascular events.
REFERENCES:
Byrne RA, Fremes S, Capodanno D, Czerny M, Doenst T, Emberson JR, et al. 2022 Joint ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG. Eur J Cardiothorac Surg. 2023 Aug 1;64(2):ezad286. doi: 10.1093/ejcts/ezad286.
Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019 Jan 7;40(2):87-165. doi: 10.1093/eurheartj/ehy394.
Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, et al. ESC Scientific Document Group. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024 Sep 29;45(36):3415-3537. doi: 10.1093/eurheartj/ehae177.
Sabatine MS, Bergmark BA, Murphy SA, O’Gara PT, Smith PK, Serruys PW et al. Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in left main coronary artery disease: an individual patient data meta-analysis. Lancet. 2021 18;398(10318):2247-2257. doi: 10.1016/S0140-6736(21)02334-5
Persson J, Yan J, Angerås O, Venetsanos D, Jeppsson A, Sjögren I, et al. PCI or CABG for left main coronary artery disease: the SWEDEHEART registry. Eur Heart J. 2023 Aug 7;44(30):2833-2842. doi: 10.1093/eurheartj/ehad369.
Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, B et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan 18;145(3):e4-e17. doi: 10.1161/CIR.0000000000001039.
Myers PO, Beyersdorf F, Sadaba R, Milojevic M. European Association for Cardio-Thoracic Surgery Statement regarding the 2021 American Heart Association/American College of Cardiology/Society for Cardiovascular Angiography and Interventions Coronary Artery Revascularization guidelines. Eur J Cardiothorac Surg. 2022 Jun 15;62(1):ezac060. doi: 10.1093/ejcts/ezac060.
Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O’Brien SM, Boden WE, et al.; ISCHEMIA Research Group. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020 Apr 9;382(15):1395-1407. doi: 10.1056/NEJMoa1915922.
Head SJ, Milojevic M, Daemen J, Ahn JM, Boersma E, Christiansen EH, et al. Mortality after coronar artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet. 2018 Mar 10;391(10124):939-948. doi: 10.1016/S0140-6736(18)30423-9.
Farkouh ME, Domanski M, Dangas GD, Godoy LC, Mack MJ, Siami FS, et al. Long-term survival following multivessel revascularization in patients with diabetes: the FREEDOM follow-on study. J Am Coll Cardiol 2019;73:629–38. doi: 10.1016/j.jacc.2018.11.001.
Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med 2011;364:1607–16. doi: 10.1056/NEJMoa1100356.
