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CLINICAL STATEMENTS AND GUIDELINES August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline 5.2 Revascularization: PCI Versus CABG Recommendations for Revascularization: PCI Versus CABG Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations Patients With CCD 1 B-R 1 In patients with CCD who require revascularization for significant left main involvement associated with high-complexity CAD, CABG is recommended in preference to PCI to improve survival.*1,2 2a B-R 2 In patients with CCD who require revasculariza- tion for multivessel CAD with complex and diffuse CAD (eg, SYNTAX score >33), it is reasonable to choose CABG over PCI to improve survival.*1,3–6 Patients With CCD at High Surgical Risk 2a B-NR 3 In patients with CCD who are appropriate for revascularization but poor candidates for surgery, it is reasonable to choose PCI over CABG to improve symptoms and reduce MACE.7–9 Patients With CCD and Diabetes 1 A 4 In patients with CCD, diabetes, and multivessel CAD with involvement of the left anterior descending artery who are appropriate candidates for CABG, CABG (with a left internal mammary artery to the left anterior descending artery) is recommended in preference to PCI to reduce mortality and repeat revascularizations.*5,10–17 2b B-R 5 In patients with CCD and diabetes who have left main stenosis and low- or intermediate-complexity CAD (eg, SYNTAX score ≤33), PCI may be considered as an alternative to CABG to reduce MACE.*10,18 *Modified from the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.19 Synopsis There are fundamental differences between how CABG and PCI restore blood flow to ischemic myocardium.20 In CABG, bypass grafts deliver blood beyond the proximal coronary segments that are usually diseased and are at risk for development of de novo lesions. Thus, in addition to the immediate benefit of CABG in treating existing lesions, CABG could offer future protection against ischemic insults by furnishing an alternative route for blood that is unhindered by upstream native CAD. The field protection is unique to CABG because PCI only treats the coronary segment where the stent is implanted with no prophylactic potential. Improved outcomes associated with CABG are largely driven by a reduction in spontaneous MI and repeat revascularization compared with PCI.3,15,21–24 However, certain subgroups of patients derive a survival benefit from CABG compared with PCI,1,2,4,25 including patients with complex or diffuse coronary disease and those with diabetes. Although the evidence for the recommendations is based on studies that included predominantly patients with CCD, some studies incorporated patients with unstable or acute coronary ischemia. The choice of revascularization therapy should be guided by Heart Team deliberations and shared decision-making (Section 4.1.3) in the context of available evidence and the patient’s specific risk profile and life expectancy. Recommendation-Specific Supportive Text 1 The SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) trial showed a significantly higher MACE and cardiac mortality rate at 5 years for the subgroup of patients with left main and high-complexity disease (defined as a SYNTAX score >33) who were treated with PCI.1 Other RCTs that compared revascularization strategies in patients with left main disease excluded patients with complex disease.20-22,26 2 The 10-year follow-up of the SYNTAX trial found a 40% higher mortality rate with PCI compared with CABG in the group of patients with triplevessel disease.4 In a pooled analysis of individual data of 11 518 patients from 11 RCTs, Head et al showed a mortality benefit with CABG over PCI in patients with multivessel disease.5 The SYNTAX score was a significant modifier of treatment effect, with higher scores (≥33) favoring CABG.5 3 In a subgroup analysis of the 10-year follow-up of the SYNTAX trial comparing PCI with CABG in patients with left main CAD, triple-vessel disease, or both, preprocedural physical and mental health status was an important modifier of the relative treatment effects of the 2 different revascularization approaches. Among patients with low Physical Component Summary (PCS) scores, low Mental Component Summary (MCS) scores, or both, no significant difference was seen in the 10-year mortality rate between PCI and CABG.7 Of the 3075 patients who were treated in the SYNTAX trial, 198 (6.4%) and 1077 (35.0%) patients were included in PCI and CABG registries, respectively. The main reason for inclusion in the CABG registry was too complex coronary anatomy, while the main reason for inclusion in the PCI registry was too high risk for surgery (70.7%).8 In the OPTIMUM (Outcomes of Percutaneous RevascularizaTIon for Management of SUrgically Ineligible Patients with Multivessel or Left Main Coronary Artery Disease) registry, patients undergoing PCI (n=726) had complex clinical profiles that were incompletely represented by surgical prediction models. Poor distal targets or conduits (18.9%), severe LV dysfunction and nonviable myocardium (16.8%), severe lung disease (10.1%), and frailty or immobility (9.7%) were among the top reasons for Downloaded from http://ahajournals.org by on October 7, 2026