p.28 抽出テキスト
Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e45 CLINICAL STATEMENTS AND GUIDELINES tortuosity, heavy calcification, complex bifurcation or trifurcation lesion, aorto-ostial stenosis, thrombotic lesion, etc) are listed in Table 6. In choosing between CABG and PCI, it is important to use the Heart Team to determine the optimal revascularization strategy, with specific considerations of anatomic complexity, medication compliance, and patient preference. 2. In the SYNTAX trial, which randomized patients with multivessel disease to a strategy of CABG or PCI with DES, the SYNTAX score was used a priori to define the complexity of disease in enrolled patients. Although the SYNTAX trial reported similar mortality rates with CABG and PCI in the overall group of patients, extended follow-up of the SYNTAX trial found a 40% higher mortality rate with PCI in the group of patients with triplevessel disease.4 Several analyses found that the extent and diffuseness of CAD on angiography, as evaluated qualitatively by visual assessment or quantitatively with the SYNTAX score,3 predicted a survival advantage of CABG over PCI.5 Specifically, the all-cause mortality rate observed after CABG was lower than that observed after PCI in patients with a diffuse CAD–associated high SYNTAX score of ≥33.2,4,5 In patients with SYNTAX scores <33, there was no difference in mortality rate.2-5 Of note, the SYNTAX trial included patients with firstgeneration DES, and significant progress has been made in stent design since this trial. 8.2 Patients With Diabetes Recommendations for Patients With Diabetes Referenced studies that support the recommendations are summarized in Online Data Supplement 14. COR LOE Recommendations 1 A 1. In patients with diabetes and multivessel CAD with the involvement of 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.1-8 2a B-NR 2. In patients with diabetes who have multivessel CAD amenable to PCI and an indication for revascularization and are poor candidates for surgery, PCI can be useful to reduce long-term ischemic outcomes.9,10 2b B-R 3. In patients with diabetes who have left main stenosis and low- or intermediate-complexity CAD in the rest of the coronary anatomy, PCI may be considered an alternative to CABG to reduce major adverse cardiovascular outcomes.5,11 Synopsis Revascularization decisions in patients with diabetes and multivessel CAD are complex and are optimized via a Heart Team approach, with consideration of left ventricular function, patient preferences, symptoms, clinical presentation, comorbidities, and expected survival.1,12-14 Diabetes is associated with 2- to 4-fold increased mortality risk from heart disease, and patients with diabetes have more aggressive atherosclerosis, more diffuse coronary lesions, smaller coronary vessels, and more extensive disease. After coronary revascularization, patients with diabetes experience a higher mortality rate and greater need for repeat revascularization procedures.15 Clinical trials of patients with diabetes and multivessel CAD have demonstrated that PCI is associated with a higher mortality rate at 5 years than that associated with CABG. The survival advantage of CABG becomes evident after 2 years and attenuates after 8 years, as patients treated with CABG experience a late mortality catch-up.2,16 Of note, CABG is associated with an increased risk of stroke that persists up to 5 years.17 The need for repeat revascularization is higher after PCI, regardless of the use of latest-generation DES.1,4-8 Recommendation-Specific Supportive Text 1. Multiple RCTs comparing PCI with CABG in patients with multivessel CAD have included patients with diabetes1-3 or have prespecified patients with diabetes as a subgroup of interest.4,5,7 The FREEDOM trial was the largest study, comparing CABG with PCI exclusively in 1900 patients with diabetes.4,5,7 Inclusion criteria for the FREEDOM trial were multivessel disease with stenosis of 70% in ≥2 major epicardial vessels involving at least 2 separate territories and without left main stenosis. After enrollment, 82% of patients in the PCI group and 85% of patients in the CABG group had 3-vessel disease, and 91% of patients had involvement of the LAD artery. At 5-year follow-up, the all-cause mortality rate was higher in patients treated with PCI than in those treated with CABG; however, the cardiovascular mortality rate was not statistically different between the groups. There was no statistical interaction between SYNTAX score, revascularization strategy, or mortality rate, which suggests that a benefit was noted irrespective of the complexity of disease.1 In the FREEDOM follow-up study, the allcause mortality rate up to 8 years was also significantly higher with PCI. A meta-analysis including individual patient data from 11 RCTs demonstrated consistent results, with a nearly 50% higher increased 5-year mortality risk among patients treated with PCI than among those treated with CABG.4,5,7 A Heart Team discussion may be useful for determining the optimal approach to care for patients with less extensive disease, including those with double-vessel disease without involvement of the left main or LAD artery. Downloaded from http://ahajournals.org by on October 7, 2026