SCAI CHAP 21 MVD PCI Flashcards
(132 cards)
1
Q
What percentage of patients undergoing percutaneous coronary interventions (PCIs) have multivessel coronary artery disease (CAD)?
A
Approximately 40% to 60% of patients undergoing PCIs have multivessel CAD.
2
Q
What approach is recommended for multivessel PCI, particularly in nonemergent situations?
A
A heart team-based approach is recommended, including careful consideration of therapeutic options and shared decision making.
3
Q
What factors should be considered when making decisions about revascularization?
A
Patient factors such as age, diabetes, renal dysfunction, and left ventricular dysfunction, as well as anatomical factors like left main disease and bifurcation lesions.
4
Q
What do the 2021 ACC/AHA/SCAI guidelines recommend for STEMI patients with multivessel CAD?
A
The guidelines recommend staged PCI of a significant noninfarct artery stenosis in selected hemodynamically STABLE patients to reduce the risk of death or myocardial infarction. In low complexity, multivessel CAD, PCI may be considered at the time of primary PCI.
5
Q
What was the outcome of the PRAMI trial regarding PCI in noninfarct coronary arteries?
A
The PRAMI trial showed a significant reduction in the risk of adverse cardiovascular events when PCI was performed in noninfarct arteries compared to PCI limited to the infarct artery only.
6
Q
What did the DANAMI-3-PRIMULTI trial find regarding complete revascularization?
A
The trial found that a fractional flow reserve-guided complete revascularization strategy was superior to treatment of the infarct-related artery only , with respect to the composite primary and point of all causes mortality, recurrent infarction and future ischemia driven revascularization of non IRA and that was in 627 patients with ST elevation myocardial infarction.
7
Q
What were the results of the CvLPRIT trial comparing complete revascularization to IRA revascularization in MVD and STEMI.
A
In the CvLPRIT trial, 10.0% of patients in the complete revascularization group met the primary endpoint (all cause mortality) compared to 21.2% in the IRA-only group.
8
Q
What did the COMPLETE trial reveal about complete revascularization?
A
The COMPLETE trial found that complete revascularization was superior to culprit-lesion-only PCI in reducing the risk of cardiovascular death or myocardial infarction in patients with ST elevation MI who have multi vessel disease. This was the largest randomized control trial enrolling 4000 patients approximately with complete revascularization, performed within 45 days of the acute myocardial infarction.
9
Q
What is important to consider in patients with complex residual CAD?
A
A heart team-based approach involving shared decision making remains important, particularly in those with complex residual CAD.
Why is that? Because the majority of the above trials excluded patients with the left main disease, CTO of the non-infract artery or complex non-infarct disease. Also 1/3 of the enrolled patients had triple vessel disease.
10
Q
When is complete revascularization at the time of primary PCI considered reasonable?
A
It is reasonable in carefully selected patients with low-complexity non-infarct artery disease, normal LV filling pressures, and normal renal function. Clinical data like lesion, complexity, he more dynamics, radiation, exposure, and contrast those should be carefully assessed before decision to pursue complete revascularization.
11
Q
A
12
Q
What is recommended for hemodynamically stable patients with STEMI and multivessel disease after successful primary PCI?
A
Staged PCI of a significant noninfarct artery stenosis is recommended to reduce the risk of death or MI.
13
Q
What may be considered for hemodynamically stable patients with STEMI and low-complexity multivessel disease?
A
PCI of a noninfarct artery stenosis may be considered at the time of primary PCI to reduce cardiac event rates.
14
Q
What should not be performed in patients with STEMI complicated by cardiogenic shock?
A
Routine PCI of a noninfarct artery at the time of primary PCI should not be performed due to the higher risk of death or renal failure.
15
Q
What is the recommendation for patients with NSTE-ACS in cardiogenic shock regarding multivessel PCI?
A
Routine multivessel PCI of nonculprit lesions in the same setting should not be performed.
16
Q
What is recommended for patients with SIHD and multivessel CAD appropriate for CABG with severe LV systolic dysfunction?
A
CABG is recommended to improve survival.
17
Q
What is reasonable for selected patients with SIHD and multivessel CAD with mild-to-moderate LV systolic dysfunction?
A
CABG (to include an LIMA graft to the LAD) is reasonable to improve survival.
18
Q
What is recommended for patients with SIHD and significant left main stenosis?
A
CABG is recommended to improve survival.
19
Q
What is reasonable for selected SIHD patients with significant left main stenosis where PCI can provide equivalent revascularization to CABG?
A
PCI is reasonable to improve survival.
20
Q
What may be reasonable for patients with SIHD, normal ejection fraction, and significant stenosis in three major coronary arteries?
A
CABG may be reasonable to improve survival.
21
Q
What is uncertain for patients with SIHD, normal ejection fraction, and significant stenosis in three major coronary arteries regarding PCI?
A
The usefulness of PCI to improve survival is uncertain.
22
Q
What is uncertain for patients with SIHD, normal LVEF, and significant stenosis in the proximal LAD?
A
The usefulness of coronary revascularization for the sake of improved survival is uncertain.
23
Q
What is not recommended for patients with SIHD, normal LVEF, and 1- or 2-vessel CAD not involving the proximal LAD?
A
Coronary revascularization is not recommended for the sake of improved survival.
24
Q
What should not be performed in patients with SIHD who have > 1 coronary arteries that are not anatomically or functionally significant?
A
If stenosis below 70% in non-left main artery or FFR above 0.8, Coronary revascularization should not be performed with primary or sole intent to improve survival.
25
What is reasonable for patients with SIHD and multivessel CAD appropriate for either CABG or PCI?
Revascularization is reasonable to lower the risk of cardiovascular events such as myocardial infarction, urgent revascularization, or cardiac death.
26
What is recommended for patients with refractory angina despite medical therapy and significant coronary artery stenosis?
Revascularization is recommended to improve symptoms.
27
What should not be performed for patients with angina but no anatomic or physiological criteria for revascularization?
Neither CABG nor PCI should be performed.
28
What is recommended for patients requiring revascularization for significant left main CAD with high-complexity CAD?
It is recommended to choose CABG over PCI to improve survival.
29
What is reasonable for patients requiring revascularization for multivessel CAD with complex or diffuse CAD (example syntax score above 33)?
It is reasonable to choose CABG over PCI to confer a survival advantage.
30
What is recommended for patients with diabetes and multivessel CAD involving the LAD who are appropriate candidates for CABG?
CABG (with a LIMA to the LAD) is recommended in preference to PCI to reduce mortality and repeat revascularizations.
31
32
What is the recommendation for PCI in patients with diabetes and multivessel CAD who are poor candidates for surgery?
PCI can be useful to reduce long-term ischemic outcomes.
## Footnote
Class IIa, Level of Evidence B-NR
33
What is the recommendation for PCI in patients with diabetes who have left main stenosis and law or intermediate complexity, CAD (for example low syntax score)?
PCI may be considered an alternative to CABG to reduce major adverse cardiovascular outcomes.
## Footnote
Class IIb, Level of Evidence B-R
34
What is the recommendation for repeat revascularization in patients with previous CABG and a patent LIMA to the LAD?
It is reasonable to choose PCI over CABG if PCI is feasible.
## Footnote
Class IIa, Level of Evidence B-NR
35
What is the recommendation for patients with previous CABG and refractory angina on guideline directed medical therapy, that is attributable to LAD disease?
It is reasonable to choose CABG over PCI when an IMA can be used as a conduit to LAD.
## Footnote
Class IIa, Level of Evidence C-LD
36
What is the recommendation for complex CAD in patients with previous CABG?
It may be reasonable to choose CABG over PCI when an IMA can be used as a conduit to LAD.
37
What is recommended for STEMI patients with cardiogenic shock?
Culprit vessel-only primary PCI is recommended.
## Footnote
Routine PCI of noninfarct artery at the time of primary PCI received a class 3 (Level of Evidence LOE B-R) in the 2021 ACC/AHA/SCAI Guideline because of the high risk of death and renal failure.
38
What were the findings of the CULPRIT-SHOCK trial?
The trial found that the primary endpoint at 30 days , composite of death, or renal failure leading to dialysis, occurred in 45.9% in the culprit-lesion-only PCI group and in 55.4% in the multivessel PCI group.
## Footnote
The trial randomized 700 patients with multi vessel disease, acute myocardial function and cardiogenic shock to either PCI of the culprit lesion only with option of staged revascularization of non-culprit lesions or immediate multivessel PCI. Also all cause mortality was lower. Relative risk (RR) was 0.83; 95% CI, 0.71-0.96.
39
What are the risks associated with immediate multivessel PCI?
Risks include contrast nephropathy, volume overload, and ischemic complications in the nonculprit artery.
## Footnote
These risks could enhance hemodynamic deterioration.
40
What was the mortality rate at 1-year follow-up in the CULPRIT-SHOCK trial?
Mortality was similar between the two groups; 50.0% in the culprit-lesion only PCI and 56.9% in the multivessel PCI group. however, the incidence of hospitalization for heart failure was higher with culprit lesion only PCI , also repeat revascularization was more frequent with culprit lesion only PCI.
## Footnote
RR was 0.88; 95% CI, 0.76-1.01.
41
What did the meta-analysis involving 5850 patients suggest?
It confirmed similar results to CULPRIT SHOCK and suggested no benefit with multivessel PCI in cardiogenic shock with STEMI compared to culprit-only PCI.
## Footnote
There was no difference in short-term mortality (OR, 1.08; 95% CI, 0.81-1.43) or long-term mortality (OR, 0.84; 95% CI, 0.54-1.30).
42
What are the appropriate use criteria for two-vessel CAD with proximal LAD stenosis?
Appropriate either bypass or PCI, in patient with ischemic symptoms ( on two or more angina medications for all guidelines in the same box)
43
What are the recommendations for three vessel coronary artery disease with low complexity (focal stenosis or syntax Score of 22 or lower )
Appropriate, either bypass or PCI.
44
What is the recommendation for three-vessel CAD with intermediate to high CAD complexity (syntax score more than 22)?
Appropriate for bypass and may be appropriate for PCI.
45
What is the recommendation for isolated left main disease ( ostial or mid-shaft ) ?
Appropriate for either PCI or bypass.
46
What is the recommendation for left main stenosis ( ostial or mid-shaft) with low CAD burden ( 1 or 2 additional vessels with SYNTAX score of 22 or below ) ?
Appropriate for either bypass or PCI.
47
What is the recommendation for left main stenosis (bifurcation) with low CAD burden ( one or two additional vessels with syntax score of 22 or below)?
appropriate for bypass and maybe appropriate for PCI.
48
What is the recommendation for left main stenosis (bifurcation) and additional CAD with intermediate to high CAD burden ( syntax score of 22 or above)?
Appropriate for bypass and rarely appropriate for PCI.
49
What is the recommendation for nonculprit lesion in ACS for symptomatic ischemia?
If the patient has symptoms or FFR below 0.8 or positive stress test then it is appropriate for either bypass or PCI.
50
51
What were the findings of the SMILE trial regarding PCI approaches in NSTEMI ?
The SMILE trial compared one-stage versus multistage PCI approaches in NSTE , finding a significantly lower occurrence of MACE (cardiac death, recurrent myocardial function, re-hospitalization, and repeat, coronary revascularization also stroke.) in the one-stage group (13.63%) at one year, compared to the multistage group (23.19%). The second procedure was performed between three days and seven days after the index procedure.
The difference in MACE is mainly driven by lower repeat revascularization, whereas there was no difference between both groups with regard to cardiac death and myocardial infraction.
52
What did the BIOVASC trial investigate?
The BIOVASC trial was a prospective noninferiority RCT that included both STEMI and NSTEMI patients randomized to immediate or staged complete revascularization.
Composite endpoint was all cause of mortality, myocardial function, and ischemia, driven intervention or CVA. Immediate revascularization group was associated with better outcome at one year, notably lower MI and lower ischemia driven revascularization compared to the staged group.
53
What were the primary outcomes of the ISCHEMIA trial?
The ISCHEMIA trial found no reduction in ischemic cardiovascular events or death from any cause with an initial invasive strategy compared to medical therapy with respect to SIHD patients, over a three years period.
The trial randomized about 5000 patients with moderate or severe ischemia on stress, testing to either invasive strategy and medical therapy or initial medical therapy alone and angiography if medical therapy fails.
Exclusion criteria: recent, acute coronary syndrome, unprotected left main stenosis of 50% or more, LV function below 35%, class three or class four heart failure, and refractory angina.
54
What was the primary endpoint of the COURAGE trial?
The COURAGE trial showed no significant differences between PCI and medical therapy in the composite of death, MI, and stroke, or hospitalization for ACS or MI.
The trial randomized about 2200 patients with ischemia to medical therapy versus PCI.
Also, there was no difference in survival at 15 years.
Exclusion criteria: Patients with persistent class 4 angina or severely positive stress, test or refractory heart failure or LV function below 30%, and patients who are revascularized within the last six months were excluded.
55
What is the class 3 recommendation regarding multivessel PCI in patients with NSTEMI?
The 2021 revascularization guidelines provide a class 3 recommendation against routine multivessel PCI of nonculprit lesions in patients with non-ST-elevation acute coronary syndromes who present in cardiogenic shock.
56
What are the class I recommendations for CABG in patients with multivessel CAD?
Class I recommendations exist for CABG in patients with multivessel CAD and LV dysfunction (LVEF <35%) and those with LM CAD.
57
What is the recommendation for revascularization in patients with SIHD and multivessel CAD?
Revascularization is reasonable to lower the risk of cardiovascular events in patients with SIHD and multivessel CAD appropriate for either CABG or PCI (class 2a, B-R).
58
What does the meta-analysis of 89,883 patients indicate about complete revascularization?
In patients with multivessel CAD, a complete revascularization strategy is associated with improved outcomes irrespective of revascularization modality.
59
What percentage of patients with NSTEMI were enrolled in the CULPRIT-SHOCK trial?
40% of patients with NSTEMI were enrolled in the CULPRIT-SHOCK trial.
60
What was the outcome for patients randomized to culprit-only PCI in the CULPRIT-SHOCK trial?
Patients randomized to culprit-only PCI had lower rates of meeting the primary endpoint (composite of death and renal-replacement therapy at 30 days).
61
What do the 2021 revascularization guidelines recommend regarding multivessel PCI in cardiogenic shock?
The guidelines provide a class 3 (harm) recommendation against routine multivessel PCI of nonculprit lesions in patients with non-ST-elevation acute coronary syndromes (ACSs) who present in cardiogenic shock.
62
63
What was the sample size of the meta-analysis for complete revascularization in patients with multivessel disease?
The meta-analysis included 89,883 patients enrolled in randomized clinical trials and observational studies.
64
What did this meta analysis showed about the association of complete revascularization with long-term mortality?
Complete revascularization (CABG or PCI) was associated with lower long-term mortality (RR, 0.71; 95% CI, 0.65-0.77; P < .001).
65
What was the association of complete revascularization with myocardial infarction (MI) per the same meta analysis ?
Complete revascularization ( CABG OR PCI ) was associated with a lower risk of MI (RR, 0.78; 95% CI, 0.68-0.90; P = .001).
66
What is the association of complete revascularization with repeat coronary revascularization?
Complete revascularization ( CABG OR PCI ) was associated with a lower risk of repeat coronary revascularization (RR, 0.74; 95% CI, 0.65-0.83; P < .001).
Therefore, the likelihood of achieving complete revascularization should influence the decision to proceed with bypass or PCI.
67
What should influence the decision to proceed with CABG or PCI?
The likelihood of achieving complete revascularization should influence the decision to proceed with CABG or PCI.
68
What are the most common reasons for not achieving complete revascularization with PCI?
The most common reasons are CTO, bifurcation disease, and diffuse disease or small vessels.
69
Is incomplete revascularization always unacceptable?
While complete revascularization is a reasonable goal, reasonably acceptable incomplete revascularization is also an acceptable strategy in multiple scenarios.
70
In what scenarios might incomplete revascularization be acceptable?
Incomplete revascularization may be acceptable in patients with frailty, advanced age, or those in which the procedural risks outweigh the benefits.
71
72
What is the SYNTAX score used for?
To quantify the complexity of multivessel CAD and inform decisions about revascularization.
73
What was the SYNTAX score developed for?
The SYNTAX trial to grade the anatomical complexity of coronary lesions in patients with LM or three-vessel disease.
74
What does the SYNTAX score predict?
Long-term major adverse cardiac and cerebrovascular events and death in patients treated with PCI but not CABG.
75
How can the SYNTAX score be calculated?
Using an online calculator at http://www.syntaxscore.com.
76
What factors does the SYNTAX score take into account?
Dominance of the coronaries, coronary segment of lesions, diameter stenosis, trifurcation lesions, bifurcation lesions, aorto-ostial lesions, severe tortuosity, lesion length, calcification, thrombus, and diffuse disease.
77
What is the SYNTAX II score?
A score developed to provide a more individualized approach to guide decision making between CABG and PCI, including both anatomical AND clinical variables.
78
What variables are included in the SYNTAX II score?
8 variables: Anatomical SYNTAX score, age, creatinine clearance, LVEF, presence of unprotected LM CAD, peripheral vascular disease, female sex, and chronic obstructive pulmonary disease.
Syntax score II , predicted four year mortality in patient with CAD in the original study however, in another study called Excel trial, the score failed to predict the outcome.
79
What do the ESC/EACTS Guidelines recommend for patients with three-vessel CAD and low SYNTAX score ( 0-22) without diabetes?
Class I LOE A recommendation for PCI or CABG.
80
What is recommended for patients with three-vessel CAD and intermediate or high SYNTAX score ( above 22 ) without diabetes?
CABG is recommended (class I, LOE A), while PCI is class III (harm) LOE A.
81
What is recommended for patients with three-vessel CAD, low SYNTAX score, and diabetes mellitus?
CABG is recommended (class I, LOE A), while PCI has a class IIb LOE A recommendation. ( if syntax score is intermediate to high in the same scenario, bypass is indicated and PCI becomes class three or harmful).
82
What clinical characteristics favor PCI?
Severe comorbidity, advanced age, frailty, reduced life expectancy, restricted mobility, and conditions affecting rehabilitation.
83
What anatomical characteristics favor PCI?
Multivessel disease with SYNTAX score 0 to 22, anatomy likely resulting in incomplete revascularization with CABG ( poor quality native or missing conduits) , severe chest deformation or scoliosis , sequelae of chest radiation, and porcelain aorta.
84
What clinical characteristics favor CABG?
Diabetes, reduced LVEF (LVEF ≤ 35%), contraindication to dual antiplatelet therapy, and recurrent diffuse in-stent restenosis.
85
What anatomical characteristics favor CABG?
Multivessel disease with SYNTAX score ≥23, LM CAD, anatomy likely resulting in incomplete revascularization with PCI, and severely calcified lesions limiting lesion expansion.
86
What additional factors favor revascularization with CABG?
Ascending aortic pathology with indication for surgery and concomitant cardiac surgery.
87
88
What are the two scores available to assist in predicting surgical mortality?
The European System for Cardiac Operative Risk Evaluation (EuroSCORE II) and the Society of Thoracic Surgeons score.
89
What is the purpose of EuroSCORE II and the Society of Thoracic Surgeons score?
To estimate the operative in-hospital or 30-day mortality risk for patients eligible for CABG and PCI.
90
What do European guidelines emphasize regarding risk models?
There is not a single risk model that provides perfect risk assessment.
91
What are some limitations of the surgical mortality risk scores?
Limitations include specific definitions or methodology, absence of important variables like frailty, practicability of calculation, failure to reflect all relevant mortality and morbidity endpoints, and limited external validation.
92
93
What is an independent predictor of worse outcomes in coronary revascularization patients?
Reduced LV function is an independent predictor of worse outcomes in patients undergoing coronary revascularization.
94
What is the association of CABG in patients with mild-to-moderate systolic dysfunction?
CABG is associated with improved survival and LV function in patients with mild-to-moderate systolic dysfunction.
## Footnote
Meta-analysis including 7 randomized trials.
95
What were the findings of the STICH trial at 5 years regarding CABG?
The STICH trial did not show improved survival with CABG compared to medical therapy at 5 years. The trial enrolled patients with symptomatic ischemia from multi vessel disease and IV function below 35%.
At10 years, however there was lower cardiovascular events and all cause mortality for bypass group.
96
What were the findings of the STICH trial at 10 years regarding CABG?
At 10 years, CABG showed lower cardiovascular and all-cause mortality compared to medical therapy (58.9% vs 66.1%; HR, 0.84; 95% CI, 0.73-0.97; P = .02).
97
What was the primary outcome of the REVIVED trial?
The trial randomized 700 patients with LV function below 35% and extensive coronary artery disease and with myocardial viability studies, to either PCI plus optimal, medical therapy or optimal medical therapy alone.
The primary outcome evaluated was death for any cause or hospitalization for heart failure. The primary outcome occurred in 37% in the PCI group and 38% in the optimum medical therapy group with LV function similar between both groups at six month and 12 month.
98
What percentage of patients in the REVIVED trial had multivessel CAD?
38% and 51% of those randomized to PCI had 2- and 3-vessel CAD, respectively. So multi vessel disease was frequent in the trial.
99
What was the median percentage of completeness of revascularization in the PCI group of the REVIVED trial?
The median percentage of completeness of revascularization was 71% in the PCI group.
100
What did the PROTECT II study compare in patients with severely depressed LV function?
The PROTECT II study compared ventricular support using an intra-aortic balloon pump or Impella 2.5 device during nonemergent high-risk PCI.
101
What was the outcome of the PROTECT II study regarding MACE at 30 days?
The study assessed about 450 symptomatic patients with complex three vessel disease or unprotected left main and severely depressed function below 35% to either aortic balloon pump or Impella device during non-emergent high risk PCI.
There was no difference in 30-day incidence of MACE between the two groups in the PROTECT II study.
102
What trend was observed in the Impella 2.5 group at 90 days in the PROTECT II study?
A trend for improved outcomes was observed in the Impella 2.5 group at 90 days.
103
What did the substudy of PROTECT II reveal about reverse LV remodeling?
Reverse LV remodeling occurred more frequently in patients with more extensive revascularization and was associated with significantly fewer major adverse events.
Reverse left ventricular remodeling is defined as improved systolic function with absolute increase about 5%.
104
What was the percentage of major adverse events in reverse LV remodelers compared to non-remodelers?
9.7% in reverse LV remodelers versus 24.2% in non-remodelers (P < .01).
The results above suggest that selective patients may benefit from higher risk PCI with hemodynamic support who have multivessel disease, low LV function, and who are not candidate for bypass.
105
What does the PROTECT III study demonstrate?
The PROTECT III study demonstrated improved completeness of revascularization and improved 90-day outcomes compared to the PROTECT II study. impella supported high risk PCI.
106
What will the PROTECT IV trial randomize patients to?
The PROTECT IV trial will randomize patients undergoing high-risk PCI for complex CAD and reduced EF to Impella 2.5 or CP supported PCI versus IABP supported PCI.
107
108
109
What percentage of patients undergoing revascularization are diabetics?
Diabetics represent 20% to 25% of patients undergoing revascularization.
110
How does the mortality rate of diabetics following PCI compare to nondiabetics?
The mortality rate of diabetics following PCI is almost twice as high as that of nondiabetics.
111
What did the BARI trial compare?
The BARI trial compared angioplasty with CABG in the management of patients with multivessel disease.
112
What was the five-year survival rate for diabetics assigned to PCI versus CABG in the BARI trial?
Five-year survival for diabetics assigned to PCI was 65.5% compared with 80.6% for those assigned to CABG. Study was conducted before the introduction of coronary stents.
113
What survival benefit was noted in the BARI trial?
The survival benefit was evident in patients who had at least one internal mammary artery used as a conduit.
114
What did the SYNTAX trial find regarding major adverse events in diabetics receiving PCI versus CABG?
Among diabetics in the SYNTAX trial, the composite major adverse event rate was significantly higher for patients receiving PCI (46.5% in PCI group vs 29.0% in CABG group; P < .01).
115
What was the outcome of the FREEDOM trial comparing CABG and PCI in diabetic patients?
Patients in the CABG group had significantly lower rates of the composite endpoint of all-cause death, cerebrovascular accident, or MI compared with patients in the PCI group (18.7% in CABG vs 26.6% in PCI; P < .01). The trial compared bypass versus PCI in diabetic patients with multivessel disease.
116
What was the finding regarding SYNTAX scores in the FREEDOM trial?
Among patients with SYNTAX scores <22, the FREEDOM trial reported no difference between treatment groups for the composite endpoint. (Similar to the results from SYNTAX study).
117
What mortality benefit was associated with CABG in the FREEDOM trial?
There was a mortality benefit associated with CABG in patients with SYNTAX scores of 23 to 32, but not for scores of 33 or higher.
This can still be related to statistical power given that fewer than 20% of patients in this trial had a syntax score of 33 or higher.
118
What do the 2021 ACCF/AHA guidelines recommend for diabetic patients with multivessel CAD involving the LAD? 
The guidelines recommend CABG with class I LOE A for these patients. From a prognostic standpoint, internal mammary artery to LAD is superior to PCI to reduce mortality and repeat revascularization.
119
What is recommended for poor candidates for CABG who are amendable to PCI?
Revascularization with PCI is recommended with class 2a LOE B-NR to reduce long-term ischemic outcomes.
120
What do the 2018 ESC/EACTS guidelines recommend for patients with three-vessel CAD and diabetes who have low syntax score ?
CABG is recommended with class I, LOE A for patients with low SYNTAX score (0-22), while PCI has a class IIb LOE A recommendation.
121
What is the recommendation for patients with three-vessel CAD, diabetes, and intermediate or high SYNTAX score ( above 22 ) ?
CABG is recommended (class I, LOE A), while PCI is class III (harm) LOE A.
122
123
What anatomical factors influence access in multivessel PCI?
Disease complexity and patient comorbidities such as LV dysfunction and heart failure are important considerations for vascular access.
124
What device may be considered for patients with LV dysfunction undergoing high-risk interventions?
Mechanical circulatory support devices such as Impella may be considered.
125
What imaging method may be favored for vascular access site planning in complex cases?
Noninvasive imaging, for example with computed tomography, may be favored.
126
What anatomical features may favor the use of larger sheath sizes?
The presence of bifurcation lesions, CTOs, and coronary calcification may favor the use of larger sheath sizes or sheathless guides.
127
What techniques may be facilitated with the upfront use of larger sheaths?
Complex CAD requiring certain bifurcation techniques (e.g., minicrush) or atherectomy may be facilitated.
128
What should be considered for nonemergent multivessel PCI?
Elective and planned multivessel PCI should be performed following a heart team approach and shared decision making.
129
What strategies can be planned for patients with impaired renal function?
Low-dose contrast strategies can be planned upfront to minimize contrast.
Strategies include radial approach, biplane coronary angiography, physiology, and imaging.
130
What is a reasonable objective for patients with multivessel CAD?
Functional complete revascularization is a reasonable objective i.e. Physiology or stress test.
131
What can be used to improve the selection of lesions for PCI?
Noninvasive or invasive assessments of ischemia and functional significance can be used.
132
What metrics should be assessed regularly during multivessel PCI?
Radiation and contrast dose are important metrics that should be assessed regularly.
