Multivessel coronary artery disease: quantifying how recent trials should influence clinical practice

The majority (70%) of coronary revascularizations concern patients with multivessel disease (MVD). Treatment options include medical therapy, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). CABG surgery has been shown to improve survival compared with medical therapy. PCI relieves angina compared with medical therapy and is equivalent to CABG in low complex MVD. Other benefits are currently being evaluated in ongoing trials. In complex MVD, CABG results in lower rates of long-term mortality, myocardial infarction and repeat revascularization compared with PCI. These results are more pronounced in diabetics and in patients with lesions that are anatomically more complex. The application of the results of clinical trials may be limited due to restrictive eligibility criteria. Comparative effectiveness studies are, therefore, needed to complement the results of trials, but also have inherent limitations. Inappropriateness criteria provide an important tool to measure how evidence from trials, large registries and guidelines is integrated in clinical practice. Checklists and decision aids may also lead to better application of the latest evidence and lower rates of inappropriate use. Decision-making is centered around heart team discussions and risk scores. Economic considerations will increasingly be included in decision-making, since the economic impact of ischemic heart disease is high and the growth of healthcare expenditure is unsustainable. In this context, CABG is associated with higher upfront costs, but is economically attractive at long-term follow-up.