Coronary Revascularization in High-Risk Stable Patients With Significant Comorbidities: Challenges in Decision-Making

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Surgery

Background:

• A growing number of complex, high-risk patients with stable ischemic heart disease (SIHD) require consideration for coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI).
• These patients are typically older, present with complex coronary artery disease, and have significant comorbidities, including frailty.
• Existing literature often lacks sufficient data on procedural risks and outcomes for this specific demographic, as studies typically focus on younger populations with lower comorbidity burdens.

Purpose of the Study:

• To review the challenges in assessing procedural risks and outcomes for CABG and PCI in complex high-risk SIHD patients.
• To highlight the need for improved risk stratification and evidence-based decision-making for revascularization in this population.
• To emphasize the limitations of current risk models and the necessity for further research.

Main Methods:

• Review of existing literature and procedural registries concerning risk assessment in SIHD patients undergoing revascularization.
• Analysis of initiatives to recalibrate and expand risk models for higher-risk patient groups.
• Discussion of the implications of evidence gaps for clinical practice and patient management.

Main Results:

• Current risk models derived from procedural registries have limitations when applied to complex high-risk SIHD patients.
• There is a recognized need for better assessment of risks, quality, and benefits of coronary revascularization in this population.
• Significant evidence gaps exist regarding the efficacy and safety of revascularization strategies in complex high-risk SIHD patients.

Conclusions:

• Clinicians and patients must understand the limitations of current risk scores when evaluating treatment options for complex high-risk SIHD.
• Future randomized controlled trials and expanded registries are crucial to address evidence gaps.
• A multidisciplinary heart team approach is essential for optimal decision-making in managing these patients.