Читать книгу Interventional Cardiology - Группа авторов - Страница 291

Broadly speaking, revascularization is appropriate for patients with limiting symptoms despite optimal medical therapy, as well as those with strongly positive stress tests, proximal multivessel disease, and active patients who prefer an interventional approach over medical therapy. The choice between PCI and CABG in any one patient is determined by extent of disease, the risks of the procedure, likelihood of success, and ability to achieve complete revascularization with the two strategies as well as diabetic status and patient preference. While medical therapy is the cornerstone of treatment of stable angina, it is important to remember that there is no evidence that medical therapy alone improves prognosis in high risk patients, as defined in the clinical trials of medical treatment vs CABG.

Patients with significant proximal LAD artery disease have a survival advantage with CABG over medical therapy, even in the absence of severe symptoms, LV dysfunction, or other lesions. PCI provides similar results among patients who have suitable anatomy for PCI of the proximal LAD and normal LV function (Tables 11.2 and 11.3).

CABG offers a survival advantage over medical therapy in patients with severe symptoms and three vessel disease, even in the absence of proximal LAD involvement or LV dysfunction. Patients with three vessel disease and LV dysfunction should have CABG. PCI is an alternative to CABG for three vessel disease in those with angiographically suitable targets and normal LV function (e.g., SYNTAX score ≤22; Tables 11.2 and 11.3). Surgical revascularization is recommended for significant left main disease though PCI is an alternative in patients with SYNTAX score of ≤22, and may be considered for those with a SYNTAX score of 23–32 (Tables 11.2 and 11.3).

In patients with diabetes mellitus, in the setting of multivessel or diffuse disease, there is a survival advantage with CABG over PCI. PCI is reasonable for diabetics with discrete two vessel disease (e.g., SYNTAX score ≤22) and preserved LV function.

For the majority of patients with stable CAD who do not fall into the subgroups described, there is no documented survival advantage with revascularization. PCI and CABG should be offered for the treatment of symptoms refractory to medical therapy. The guidelines state that both forms of revascularization are suitable for two vessel disease, but in current practice the majority of these patients and those with single vessel disease are treated with PCI unless the lesions are angiographically unsuitable, or involve the proximal LAD [57].

Revascularization in asymptomatic patients should only be considered with the goal of improving prognosis. The guidelines for the treatment of asymptomatic patients are similar to those for symptomatic patients. However, the level of evidence for asymptomatic patients is weaker as the clinical trials have mainly included symptomatic patients. The presence and extent of inducible ischemia are important considerarions for guiding management in asymptomatic patients.