PercutaneousorSurgicalPercutaneousorSurgicalRevascularizationforMultivesselRevascularizationforMultivesselCoronaryArteryDisease?CoronaryArteryDisease?VergheseMathew,MD,FACCVergheseMathew,MD,FACCConsultant,DivisionofCardiovascularDiseasesandConsultant,DivisionofCardiovascularDiseasesandDepartmentofRadiologyDepartmentofRadiologyProfessorofMedicine,MayoClinicCollegeofMedicineProfessorofMedicine,MayoClinicCollegeofMedicineRevascularizationStrategiesRevascularizationStrategiesHowdowedecide?AnatomyClinicalPatientpresentationpreferenceRiskvs.BenefitInvasiveTherapiesInvasiveTherapiesLowRiskPatientLowRiskPatientHighRiskPatientHighRiskPatientSomeacuteSomeacuteriskriskLesslong-termriskLesslong-termriskreductionreductionGreateracuteGreateracuteriskriskGreaterlong-termGreaterlong-termriskreductionriskreduction12-YearSurvivalinPatientswithCAD12-YearSurvivalinPatientswithCAD7354210255075100>5035-49<35EmondMetal:Circ90:2645,199423,467Medically-TreatedPatientsinCASSRegistry23,467Medically-TreatedPatientsinCASSRegistryLVEFCP1203018-212-YearSurvivalinPatientswithCAD12-YearSurvivalinPatientswithCAD887450400255075100NoCAD1vessel2vessel3vesselEmondMetal:Circ90:2645,199423,467Medically-TreatedPatientsinCASSRegistry23,467Medically-TreatedPatientsinCASSRegistryCP1203018-1ClinicalPresentationClinicalPresentation•AgeAge•AcuteischemicsyndromeversuschronicAcuteischemicsyndromeversuschronicstableanginastableangina•Priorcardiachistory(MI,CABG,Priorcardiachistory(MI,CABG,intervention)intervention)•Co-morbidconditions(diabetes,Co-morbidconditions(diabetes,cerebrovasculardisease,renaldisease,cerebrovasculardisease,renaldisease,lungdisease)lungdisease)•FunctionalimpairmentFunctionalimpairment•IschemicburdenIschemicburdenExtensionofSurvivalwithCABGvsMedicalExtensionofSurvivalwithCABGvsMedicalTherapyAfter10YearsTherapyAfter10Years-4-202468101214161820CP1203018-14Extensionofsurvival(mo)Extensionofsurvival(mo)YusufSetal:Lancet344:563,1994YusufSetal:Lancet344:563,1994OverallOverallVesseldisease1/2vessels3vesselsLeftmainVesseldisease1/2vessels3vesselsLeftmainLVfunctionNormalAbnormalLVfunctionNormalAbnormalExercisetestNormalAbnormalExercisetestNormalAbnormalAnginaClass0,I,IIClassIII,IVAnginaClass0,I,IIClassIII,IVLowModerateHighLowModerateHighLowModerateHighLowModerateHighVAriskscoreVAriskscoreStepwiseriskscoreStepwiseriskscore3011246-8506070809010003657301,0951,4601,825506070809010003657301,0951,4601,825506070809010003657301,0951,4601,825506070809010003657301,0951,4601,825CABGvsStentingforMVDMeta-AnalysisofARTS,ERACI-CABGvsStentingforMVDMeta-AnalysisofARTS,ERACI-II,MASS-IIandSOSII,MASS-IIandSOSCirc118,2008Circ118,2008DaysEvent-FreeSurvivalAnalysisofDeath1,5181,5181,4721,4721,4561,4561,4401,4401,4061,4061,3471,3471,5331,5331,4791,4791,4571,4571,4391,4391,4121,4121,3491,349OverallOverallsurvival(%)survival(%)P=0.78P=0.78DaysRepeatRevascularization1,5181,5181,2041,2047727727407407077076656651,5331,5331,4281,428927927911911882882855855P<0.0001P<0.0001OverallOverallsurvival(%)survival(%)DaysDeath,StrokeorMI1,5181,5181,3811,3819139138968968728728468461,5331,5331,3771,377908908891891868868845845OverallOverallsurvival(%)survival(%)P=0.64P=0.64DaysMajorAdverseCardiacandCerebrovascularEvents1,5181,5181,1531,1537297296916916576576166161,5331,5331,3321,332867867846846812812785785P<0.0001P<0.0001OverallOverallsurvival...
