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Updated: Mar 31, 2026
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Physiology-guided myocardial revascularisation in complex multivessel coronary artery disease: beyond the 2014
Jan J Piek1, Bimmer E Claessen1, Justin E Davies2
1AMC Heart Center, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands.
Insights
Percutaneous coronary intervention (PCI) guided by physiology is a viable alternative to bypass surgery for complex multivessel disease. Current guidelines overlook this approach for stable angina patients with significant coronary artery disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiothoracic Surgery
Background:
- Revascularization for multivessel coronary artery disease (MVD) involves Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Graft Surgery (CABG).
- Clinical decisions are made by a heart team, considering European guidelines for myocardial revascularization.
- Current guidelines recommend CABG over PCI for stable angina with three-vessel disease and high SYNTAX scores (≥23).
Purpose of the Study:
- To argue for the inclusion of physiology-guided PCI in treatment recommendations for MVD.
- To highlight the potential of current-generation drug-eluting stents in physiology-guided PCI for complex MVD.
Main Methods:
- This is a viewpoint article, not a clinical trial.
- It analyzes current European guidelines on myocardial revascularization.
- It discusses the role of functional assessment in guiding PCI for MVD.
Main Results:
- Current guidelines do not provide recommendations for physiology-guided PCI in MVD.
- The authors advocate for considering physiology-guided PCI as a reasonable alternative.
Conclusions:
- Physiology-guided PCI using modern drug-eluting stents is a potential alternative for complex multivessel disease.
- The omission of physiology-guided PCI recommendations in current guidelines is considered an oversight.
Abstract:
For patients with multivessel coronary artery disease there are two options for revascularisation: Percutaneous coronary intervention (PCI) or Coronary Artery Bypass Graft Surgery (CABG). In daily clinical practice, a heart team consisting of an interventional cardiologist and a cardiothoracic surgeon decide on the most appropriate mode of revascularization. The current European guidelines on myocardial revascularisation include updated recommendations for patients with multivessel coronary artery disease. In patients with stable angina, three-vessel disease and a SYNTAX score of 23-32 or >32 a class I level of evidence A recommendation for CABG was issued as compared to PCI which received a class III recommendation. Although the authors of this viewpoint greatly appreciate the efforts of the guideline committee, we believe that it was an oversight not to include recommendations on physiology-guided PCI in multivessel disease (MVD). In this viewpoint, it is argued that physiology-guided revascularization using current-generation drug-eluting stents is a reasonable alternative for complex multivessel disease.
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