Coronary Revascularization · CABG vs PCI

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Disease (left main/multivessel/SYNTAX) + ischemia
   Extent/complexity (SYNTAX)? Acute? Ischemic burden?
   • Stable, mild symptoms, no significant ischemia/low-risk anatomy → Stable low-risk → best medical therapy
   • Left main or multivessel + diabetes or high complexity (SYNTAX ≥33) → Left main/multivessel diabetes → CABG
   • Single/double vessel (or low-complexity left main), SYNTAX <22, anatomy suitable for PCI → Low-complexity → PCI
   • ACS/STEMI (acute) → ACS/STEMI → emergency reperfusion
2. [End] Stable low-risk → best medical therapy
   Stable, mild symptoms, no significant ischemia/low-risk → best medical therapy (GDMT) + risk-factor control; non-invasive ischemia/FFR assessment to guide whether to revascularize.
3. [End] Left main/multivessel diabetes → CABG
   Left main, multivessel + diabetes (FREEDOM), high SYNTAX (≥33)/diffuse complex → coronary artery bypass grafting (CABG) for better long-term outcome and complete revascularization; Heart Team decision.
4. [End] Low-complexity → PCI
   Single/double vessel (or selected low-SYNTAX left main), low complexity (SYNTAX <22), suitable anatomy → PCI (drug-eluting stent); minimally invasive, faster recovery.
5. [End] ACS/STEMI → emergency reperfusion
   Acute coronary syndrome/STEMI → emergency reperfusion: STEMI preferably primary PCI (fibrinolysis then transfer if not timely); early invasive strategy for high-risk NSTE-ACS; treat the culprit vessel first.

Source guidelines & references

• Coronary revascularization (2021 ACC/AHA/SCAI; ESC; FREEDOM; SYNTAX)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways