Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Surgery

Background:

• Coronary artery disease (CAD) burden is increasing, often with comorbidities and advanced age.
• Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are revascularisation options, but many eligible patients are excluded from trials.
• Guideline recommendations for CAD revascularisation are comprehensive but do not cover all complex patient scenarios.

Purpose of the Study:

• To review clinical scenarios in coronary artery disease (CAD) revascularisation not adequately addressed by current guidelines and trials.
• To inform heart teams and trainees on nuanced management strategies for complex CAD presentations.
• To highlight knowledge gaps and research needs in coronary revascularisation.

Main Methods:

• Narrative review of common clinical scenarios beyond contemporary guidelines.
• Summary of existing evidence for coronary revascularisation in challenging patient populations.
• Identification of research gaps, including underrepresentation and emerging techniques.

Main Results:

• Identified complex CAD cases that fall outside current trial eligibility criteria.
• Highlighted underrepresentation of female and non-White patients in research.
• Noted the emergence of new minimally invasive and hybrid revascularisation techniques.

Conclusions:

• Evidence-based medicine, patient preferences, shared decision-making, and heart team communication are crucial for managing complex CAD.
• Further research is needed to address knowledge gaps and ensure equitable representation in clinical trials.
• Tailored management strategies are essential for patients with complex coronary artery disease who may benefit from PCI or CABG.