2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary

Abstract

HomeCirculationVol. 124, No. 232011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive SummaryA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions Writing Committee Members* Glenn N. Levine, MD, FACC, FAHA, Eric R. Bates, MD, FACC, FAHA, James C. Blankenship, MD, FACC, FSCAI, Steven R. Bailey, MD, FACC, FSCAI, John A. Bittl, MD, FACC, Bojan Cercek, MD, FACC, FAHA, Charles E. Chambers, MD, FACC, FSCAI, Stephen G. Ellis, MD, FACC, Robert A. Guyton, MD, FACC, Steven M. Hollenberg, MD, FACC, Umesh N. Khot, MD, FACC, Richard A. Lange, MD, FACC, FAHA, Laura Mauri, MD, MSC, FACC, FSCAI, Roxana Mehran, MD, FACC, FAHA, FSCAI, Issam D. Moussa, MD, FACC, FAHA, FSCAI, Debabrata Mukherjee, MD, FACC, FSCAI, Brahmajee K. Nallamothu, MD, FACC and Henry H. Ting, MD, FACC, FAHA Writing Committee Members* Search for more papers by this author , Glenn N. LevineGlenn N. Levine Search for more papers by this author , Eric R. BatesEric R. Bates Search for more papers by this author , James C. BlankenshipJames C. Blankenship Appendix 1 Search for more papers by this author , Steven R. BaileySteven R. Bailey Appendix 1 Search for more papers by this author , John A. BittlJohn A. Bittl Search for more papers by this author , Bojan CercekBojan Cercek Search for more papers by this author , Charles E. ChambersCharles E. Chambers Search for more papers by this author , Stephen G. EllisStephen G. Ellis Appendix 1 Search for more papers by this author , Robert A. GuytonRobert A. Guyton Appendix 1 Search for more papers by this author , Steven M. HollenbergSteven M. Hollenberg Appendix 1 Search for more papers by this author , Umesh N. KhotUmesh N. Khot Appendix 1 Search for more papers by this author , Richard A. LangeRichard A. Lange Search for more papers by this author , Laura MauriLaura Mauri Appendix 1 Search for more papers by this author , Roxana MehranRoxana Mehran Appendix 1 Search for more papers by this author , Issam D. MoussaIssam D. Moussa Search for more papers by this author , Debabrata MukherjeeDebabrata Mukherjee Search for more papers by this author , Brahmajee K. NallamothuBrahmajee K. Nallamothu Search for more papers by this author and Henry H. TingHenry H. Ting Search for more papers by this author Originally published7 Nov 2011https://doi.org/10.1161/CIR.0b013e31823a5596Circulation. 2011;124:2574–2609is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2011: Previous Version 1 Table of ContentsPreamble........25751. Introduction........25781.1. Methodology and Evidence Review........25781.2. Organization of the Writing Committee........25781.3. Document Review and Approval........25781.4. PCI Guideline Scope........25782. CAD Revascularization: Recommendations........25782.1. Heart Team Approach to Revascularization Decisions........25802.2. Revascularization to Improve Survival........25802.3. Revascularization to Improve Symptoms........25812.4. Clinical Factors That May Influence the Choice of Revascularization........25822.4.1. Dual Antiplatelet Therapy Compliance and Stent Thrombosis........25822.5. Hybrid Coronary Revascularization........25823. Preprocedural Considerations: Recommendations Recommendations........25823.1. Radiation Safety........25823.2. Contrast-Induced Acute Kidney Injury........25833.3. Anaphylactoid Reactions........25833.4. Statin Treatment........25833.5. Bleeding Risk........25833.6. PCI in Hospitals Without On-Site Surgical Backup........25834. Procedural Considerations: Recommendations........25834.1. Vascular Access........25834.2. PCI in Specific Clinical Situations........25834.2.1. Unstable Angina/Non–ST-Elevation Myocardial Infarction........25834.2.2. ST-Elevation Myocardial Infarction........25844.2.3. Cardiogenic Shock........25854.2.4. Revascularization Before Noncardiac Surgery........25854.3. Coronary Stents........25864.4. Adjunctive Diagnostic Devices........25864.4.1. Fractional Flow Reserve........25864.4.2. Intravascular Ultrasound........25864.5. Adjunctive Therapeutic Devices........25864.5.1. Coronary Atherectomy........25864.5.2. Thrombectomy........25864.5.3. Laser Angioplasty........25874.5.4. Cutting Balloon Angioplasty........25874.5.5. Embolic Protection Devices........25874.6. Percutaneous Hemodynamic Support Devices........25874.6.1. Oral Antiplatelet Therapy........25884.6.2. Intravenous Antiplatelet Therapy........25884.6.3. Anticoagulant Therapy........25894.6.4. No-Reflow Pharmacological Therapies........25894.7. PCI in Specific Anatomic Situations........25894.7.1. Chronic Total Occlusions........25894.7.2. Saphenous Vein Grafts........25894.7.3. Bifurcation Lesions........25894.7.4. Aorto-Ostial Stenoses........25894.7.5. Calcified Lesions........25914.8. PCI in Specific Patient Populations........25914.8.1. Chronic Kidney Disease........25914.9. Periprocedural Myocardial Infarction Assessment........25914.10. Vascular Closure Devices........25915. Postprocedural Considerations: Recommendations........25915.1. Postprocedural Antiplatelet Therapy........25915.1.1. Proton Pump Inhibitors and Antiplatelet Therapy........25915.1.2. Clopidogrel Genetic Testing........25925.1.3. Platelet Function Testing........25925.2. Restenosis........25925.2.1. Exercise Testing........25925.2.2. Cardiac Rehabilitation........25926. Quality and Performance Considerations: Recommendations........25926.1. Quality and Performance........25926.2. Certification and Maintenance of Certification........25926.3. Operator and Institutional Competency and Volume........2592References........2593Appendix 1. Author Relationships With Industry and Other Entities (Relevant)........2605Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant)........2608Jacobs Alice K., MD, FACC, FAHAPreambleThe medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice.Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate if the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceA recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.*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.†For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines.Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, where the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all such current relationships, as well as those existing 12 months previously. In December 2009, the ACCF and AHA implemented a new policy for relationships with industry and other entities (RWI) that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 for the ACCF/AHA definition of relevance). These statements are reviewed by the Task Force and all members during each conference call and/or meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members are not permitted to write, and must recuse themselves from voting on, any recommendation or section to which their RWI apply. Members who recused themselves from voting are indicated in the list of writing committee members, and section recusals are noted in Appendix 1. Authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, writing committee members' comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at www.cardiosource.org/ACC/About-ACC/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of the writing committee was supported exclusively by the ACCF, AHA, and the Society for Cardiovascular Angiography and Interventions (SCAI) without commercial support. Writing committee members volunteered their time for this activity.In an effort to maintain relevance at the point of care for practicing physicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference.In April 2011 the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the ACCF/AHA guidelines are cited as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA.1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted through November 2010, as well as selected other references through August 2011. Searches were limited to studies, reviews, and other evidence conducted in human subjects and that were published in English. Key search words included but were not limited to the following: ad hoc angioplasty, angioplasty, balloon angioplasty, clinical trial, coronary stenting, delayed angioplasty, meta-analysis, percutaneous transluminal coronary angioplasty, randomized controlled trial, percutaneous coronary intervention (PCI) and angina, angina reduction, antiplatelet therapy, bare-metal stents (BMS), cardiac rehabilitation, chronic stable angina, complication, coronary bifurcation lesion, coronary calcified lesion, coronary chronic total occlusion, coronary ostial lesions, coronary stent (BMS and drug-eluting stents [DES]; and BMS versus DES), diabetes, distal embolization, distal protection, elderly, ethics, late stent thrombosis, medical therapy, microembolization, mortality, multiple lesions, multivessel, myocardial infarction, non–ST-elevation myocardial infarction (NSTEMI), no-reflow, optical coherence tomography, proton pump inhibitor, return to work, same-day angioplasty and/or stenting, slow flow, stable ischemic heart disease (SIHD), staged angioplasty, STEMI, survival, and unstable angina (UA). Additional searches cross-referenced these topics with the following subtopics: anticoagulant therapy, contrast nephropathy, PCI-related vascular complications, unprotected left main PCI, multivessel coronary artery disease (CAD), adjunctive percutaneous interventional devices, percutaneous hemodynamic support devices, and secondary prevention. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. References selected and published in this document are representative and not all-inclusive.Because the executive summary contains only the recommendations, the reader is encouraged to consult the full-text guideline4 for additional detail on the recommendations and guidance on the care of the patient undergoing PCI.1.2. Organization of the Writing CommitteeThe committee was composed of physicians with expertise in interventional cardiology, general cardiology, critical care cardiology, cardiothoracic surgery, clinical trials, and health services research. The committee included representatives from the ACCF, AHA, and SCAI.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers nominated by the ACCF, AHA, and SCAI, as well as 21 individual content reviewers (including members of the ACCF Interventional Scientific Council and ACCF Surgeons' Scientific Council). All information on reviewers' RWI was distributed to the writing committee and is published in this document (Appendix 2). This document was approved for publication by the governing bodies of the ACCF, AHA, and SCAI.1.4. PCI Guideline ScopeThe evolution of the PCI guideline reflects the growth of knowledge in the field and parallels the many advances and innovations in the field of interventional cardiology, including primary PCI, BMS and DES, intravascular ultrasound (IVUS) and physiologic assessments of stenosis, and newer antiplatelet and anticoagulant therapies. The 2011 iteration of the guideline continues this process, addressing ethical aspects of PCI, vascular access considerations, CAD revascularization including hybrid revascularization, revascularization before noncardiac surgery, optical coherence tomography, advanced hemodynamic support devices, no-reflow therapies, and vascular closure devices. Most of this document is organized according to “patient flow,” consisting of preprocedural considerations, procedural considerations, and postprocedural considerations. The focus of this guideline is the safe, appropriate, and efficacious performance of PCI. The risks of PCI must be balanced against the likelihood of improved survival, symptoms, or functional status. This is especially important in patients with SIHD.In a major undertaking, the STEMI, PCI, and coronary artery bypass graft (CABG) surgery guidelines were written concurrently, with additional collaboration with the SIHD guideline writing committee, allowing greater collaboration between the different writing committees on topics such as PCI in STEMI and revascularization strategies in patients with CAD (including unprotected left main PCI, multivessel disease revascularization, and hybrid procedures).In accordance with direction from the Task Force and feedback from readers, in this iteration of the guideline, the text has been shortened, with an emphasis on summary statements rather than detailed discussion of numerous individual trials. Online supplemental evidence and summary tables have been created to document the studies and data considered for new or changed guideline recommendations.2. CAD Revascularization: RecommendationsRecommendations and text in this section are the result of extensive collaborative discussions between the PCI and CABG writing committees, as well as key members of the SIHD and UA/NSTEMI writing committees. Certain issues, such as older versus more contemporary studies, primary analyses versus subgroup analyses, and prospective versus post hoc analyses, have been carefully weighed in designating COR and LOE; they are addressed in the appropriate corresponding text.4 The goals of revascularization for patients with CAD are to 1) improve survival and/or 2) relieve symptoms. The following text contains recommendations for revascularization to improve survival and symptoms, and they are presented in Tables 2 and 3.Table 2. Revascularization to Improve Survival Compared With Medical TherapyTable 2. Revascularization to Improve Survival Compared With Medical Therapy*In patients with multivessel disease who also have diabetes, it is reasonable to choose CABG (with LIMA) over PCI.54,66–73(Class IIa; LOE: B).CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not applicable; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; 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; UPLM, unprotected left main disease; and VT, ventricular tachycardia.Table 3. Revascularization to Improve Symptoms With Significant Anatomic (≥50% Left Main or ≥70% Non–Left Main CAD) or Physiological (FFR ≤0.80) Coronary Artery StenosesTable 3. Revascularization to Improve Symptoms With Significant Anatomic (≥50% Left Main or ≥70% Non–Left Main CAD) or Physiological (FFR ≤0.80) Coronary Artery StenosesCABG indicates coronary artery bypass graft; CAD, coronary artery disease; COR, class of recommendation; FFR, fractional flow reserve; GDMT, guideline-directed medical therapy; LOE, level of evidence; N/A, not applicable; PCI, percutaneous coronary intervention; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; and TMR, transmyocardial laser revascularization.Revascularization recommendations in this section are predominantly based on studies of patients with symptomatic SIHD and should be interpreted in this context. As discussed later in this section, recommendations on the type of revascularization are, in general, applicable to patients with UA/NSTEMI. In some cases (eg, unprotected left main CAD), specific recommendations are made for patients with UA/NSTEMI or STEMI.2.1. Heart Team Approach to Revascularization DecisionsClass IA Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD.5–7(Level of Evidence: C)Class IIaCalculation of the Society of Thoracic Surgeons and SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores is reasonable in patients with unprotected left main and complex CAD.7–14(Level of Evidence: B)2.2. Revascularization to Improve SurvivalLeft Main CAD RevascularizationClass ICABG to improve survival is recommended for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis.15–21(Level of Evidence: B)Class IIaPCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: 1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (eg, a low SYNTAX score [≤22], ostial or trunk left main CAD); and 2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, Society of Thoracic Surgeons–predicted risk of operative mortality ≥5%).8,10,11,22–40,106(Level of Evidence: B)PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG.11,27,29–31,36,37,39–41(Level of Evidence: B)PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG.24,42,43(Level of Evidence: C)Class IIbPCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: 1) anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (eg, low-intermediate SYNTAX score of <33, bifurcation left main CAD); and 2) clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; Society of Thoracic Surgeons–predicted risk of operative mortality >2%).8,10,11,22–40,44(Level of Evidence: B)Class III: HARMPCI to improve survival should not be performed in stable patients with significant (≥50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG.8,10,11,15–23(Level of Evidence: B)Non–Left Main CAD RevascularizationClass ICABG to improve survival is beneficial in patients with significant (≥70% diameter) stenoses in 3 major coronary arteries (with or without involvement of the proximal left anterior descending [LAD]) or in the proximal LAD plus 1 other major coronary artery.17,21,45–48(Level of Evidence: B)CABG or PCI to improve survival is beneficial in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant (≥70% diameter) stenosis in a major coronary artery.(CABG Level of Evidence: B49–51; PCI Level of Evidence: C49)Class IIaCABG to improve survival is reasonable in patients with significant (≥70% diameter) stenoses in 2 major coronary arteries with severe or extensive myocardial ischemia (eg, high-risk criteria on stress testing, abnormal intracoronary hemodynamic evaluation, or >20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium.52–55(Level of Evidence: B)CABG to improve survival is reasonable in patients with mild-moderate left ventricular systolic dysfunction (ejection fraction 35% to 50%) and significant (≥70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization.21,56–60(Level of Evidence: B)CABG with a left internal mammary artery graft to improve survival is reasonable in patients with significant (≥70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia.21,48,61,62(Level of Evidence: B)It is reasonable to choose CABG over PCI to improve survival in patients with complex 3-vessel CAD (eg, SYNTAX score >22) with or without involvement of the proximal LAD artery who are good candidates for CABG.23,38,48,63,64(Level of Evidence: B)CABG is probably recommended in preference to PCI to improve surv