**10.1. Establishing a general approach**

Decisions regarding revascularization are complex and have been founded on decades of evidence. This body of evidence has evolved in parallel with advances in treatment but also a patient population with increasing medical complexity. Therefore, a contemporary approach to MVD and revascularization must be founded on an understanding of the wide spectrum of disease severity, advances in medical/surgical therapy, diversity in patient populations, patient preference and social circumstances. Optimal treatment strategies must apply the most current evidence in an appropriate clinical context. Furthermore, guiding principles of management with a multidisciplinary 'Heart Team' approach should be the cornerstone of state of the art treatment of multivessel coronary artery disease as supported by recent revascularization guidelines [14]. The basic approach should address a number of basic clinical questions which address the (1) therapeutic goals of the case, (2) the presence or absence of clinical evidence to support revascularization, (3) the presence/absence of prognostic factors that may make surgical revascularization more favorable, (4) whether the anatomy favor PCI or CABG, (5) is the patient a good surgical candidate should prognostic disease be present, (6) does the patient have any particular preferences and (7) are there ambiguities that would benefit from further discussion by a Heart Team [Table 4].


**Table 4.** Key clinical questions forming the basis of the therapeutic decision for management of multivessel coronary artery disease.

The fundamental basis of our decisions rest on what therapeutic goals can be achieved: *improvement of survival, improvement of symptoms or both*. It is important to make this distinction because although the goal would naturally to improve on both; consider the following two clinical scenarios:


If the intent is to improve survival, there is good evidence that supports revascularization in certain patient populations: significant left main (>50%) or 3VD, 2VD with proximal LAD with diabetes LV dysfunction and/or high burden of functional ischemia).

If the intent is primarily to *improve symptoms (eg. The clinical profile undermines the prognostic benefit of surgical revascularization)*, there is good evidence that revascularization with PCI is of benefit in those who are symptomatic despite optimal medical therapy if technically feasible. But with advances in medical therapy, it is reasonable to maximize medical treatment before considering revascularization [56].
