**10. Angioplasty versus bypass surgery: An evolving complex decision analysis**

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

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**•** In a 50 year-old asymptomatic patient with 70% distal LM, CABG is the treatment of choice regardless of his symptom profile because of known survival benefit with surgical revas‐

**•** In a 90 year-old, medically optimized, CCS class III patient who has 3VD and normal ejection fraction, his age may undermine any treatment for the purposes of prognosis, hence PCI may be favored if technically feasible as the overriding goal is for relief of symptoms. **(Class**

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

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

Based on existing evidence and guidelines, we have developed an algorithm that may help guide decision-making in the management of MVD [Figure10]. There are a number of factors that support surgical revascularization in SIHD for improving survival over medical therapy or PCI, namely: 1) LM disease, 3VD and likely some subsets of 2VD with proximal LAD; 2) MVD in the presence of mild to moderate LV dysfunction (35-49%) 3) MVD in the presence of diabetes 4) coronary anatomy of intermediate to high level of complexity (SYNTAX >22) and 5) high burden of ischemia (>12.5%). If these are present, then surgery should be considered first unless patient preference dictates otherwise **(Class I recommendation, Level B Evidence).**

If the patient does have prognostic disease, then considering the overall coronary anatomy, patients clinical profile and co-morbidities must be considered to ultimately guide the appropriate therapeutic decision. These factors may alter the likelihood of benefit from

If the patient does not appear to have prognostic disease and is not likely to prognostically benefit from revascularization, then the primary goal of treatment would be symptoms. The first goal of alleviating symptoms is medical optimization. If the patient has unacceptable symptoms despite optimal medical therapy, then revascularization (PCI or CABG) would be

revascularization and also affect the patients' potential eligibility CABG and PCI.

indicated **(Class I recommendation, Level A Evidence).**

diabetes LV dysfunction and/or high burden of functional ischemia).

clinical scenarios:

**I, Level A evidence)**[14]

considering revascularization [56].

**10.2. The decision algorithm**

cularization **(Class I, Level A evidence)**[14]
