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TABLE 1. ACCF/AHA Guidelines for Revascularization With CABG or PCI for Symptom Relief
Unprotected Left Main CAD With ≥ 50% Stenosis
CABG Use (Class/LOE)a PCI Use (Class/LOE)
Recommended (IB)
  • For stable ischemic heart disease: if low risk of procedural complications/good prognosis for long-term outcomes (eg, ostial or trunk left main CAD, SYNTAX score ≤ 22) and significant risk of adverse surgical outcomes (IIaB)
  • For UA/NSTEMI: if not a candidate for CABG (IIaB)
  • For STEMI: when TIMI flow grade < 3 and PCI can be performed more rapidly and safely than CABG (IIaC)
  • For stable ischemic heart disease: when there is a low-to-intermediate risk of procedural complications and an intermediate-to-high likelihood of good long-term outcome (eg, SYNTAX score < 33, bifurcation left main CAD) and an increased risk of adverse outcomes due to clinical characteristics/comorbidities (IIbB)
Significant Anatomic (≥ 70% Diameter Non–Left Main CAD) or
Physiologic (FFR ≤ 0.80) Non–Left Main Coronary Artery Stenosis
CABG Use (Class/LOE) PCI Use (Class/LOE)

In 3-vessel disease with or without proximal LAD artery disease:

  • Recommended (IB)
  • Preferred to PCI in patients with SYNTAX score > 22, who are good candidates for CABG (IIaB)

In 3-vessel disease with or without proximal LAD artery disease:

  • Of uncertain benefit (IIbB)

In 2-vessel disease with proximal LAD artery disease:

  • Recommended (IB)

In 2-vessel disease with proximal LAD artery disease:

  • Of uncertain benefit (IIbB)

In 2-vessel disease without proximal LAD artery disease:

  • Recommended if there is extensive ischemia (IIaB) but of uncertain benefit without extensive ischemia (IIbC)

In 2-vessel disease without proximal LAD artery disease:

  • Of uncertain benefit (IIbB)

In 1-vessel proximal LAD artery disease:

  • With LIMA for long-term benefit (IIaB)

In 1-vessel proximal LAD artery disease:

  • Of uncertain benefit (IIbB)

aLevel of evidence: A = multiple populations evaluated, data derived from multiple randomized clinical trials or meta-analyses; B = limited populations evaluated, data derived from a single randomized trial or nonrandomized studies; C = very limited populations evaluated, only consensus opinion of experts, case studies, or standard of care. Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.
Recommendations: class I (benefit >>> risk), class IIa (benefit >> risk), class IIb (benefit ≥ risk).
CABG = coronary artery bypass surgery; CAD = coronary artery disease; FFR = fractional flow reserve; LAD = left anterior descending; LOE = level of evidence; LIMA = left internal mammary artery; PCI = percutaneous coronary intervention; 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.
Adapted with permission from ACCF/AHA pocket guideline. Management of patients undergoing coronary artery revascularization. American College of Cardiology Foundation and American Heart Association. November 2011.