Kommentar zu den Leitlinien (2018) der ESC und EACTS zur Myokardrevaskularisation

The guidelines are intended to support the treatment of patients with coronary artery disease by pragmatic evidence-based recommendations. Myocardial revascularization is indicated in order to alleviate symptoms of myocardial ischemia and/or to reduce long-term mortality and morbidity. The greater the risk of ischaemia for the myocardium, the greater the prognostic benefit, which critically depends on the ability to achieve complete revascularization. Apart from cases with high-grade stenosis of large vessels, angiographic assessment alone does not suffice in order to determine if myocardial revascularization should be carried out; instead, documentation of the haemodynamic relevance by non-invasive functional testing or intracoronary physiological measurements are needed. Both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are capable of improving the prognosis when correctly indicated. The use of PCI is associated with faster recovery and lower risk of early complications, including stroke, whereas for multivessel disease with or without left main stenosis CABG in general reduces mortality and morbidity in the long run. The difference in long-term outcome between the two modalities greatly depends on the complexity of the coronary artery disease and the presence of diabetes mellitus; it is negligible with low complexity coronary artery disease but substantial with high complexity, especially in combination with diabetes. Therefore, in addition to the perioperative risk and the technical feasibility, the criteria for deciding between PCI and CABG are the extent of coronary artery involvement as gauged by the SYNTAX score, the presence of left main stem stenosis, diabetes and the possibility to achieve complete revascularization. Recommendations for individualized treatment decisions respecting the patient’s preference are best made by the heart team. The guidelines also give recommendations for myocardial revascularization in specific clinical settings, on technical aspects of PCI and CABG, as well as on adjunctive therapy.