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Published on: April 17, 2021

Revascularization of coronary artery disease in heart failure. A European Journal of Heart Failure Expert Consensus

Bernhard Haring1,2,3, Antonio Iaconelli4,5, Divaka Perera6,7

  • 1Department of Medicine IV, Clinic Hietzing, Vienna, Austria.

European Journal of Heart Failure
|July 24, 2026
PubMed

Insights

Myocardial revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) offers no benefit for heart failure with reduced ejection fraction patients on modern therapy. Revascularization decisions require heart team discussion due to conflicting evidence.

Area of Science:

  • Cardiology
  • Cardiovascular Surgery
  • Heart Failure Management

Background:

  • The role of myocardial revascularization, including percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG), in heart failure (HF) patients with coronary artery disease (CAD) remains controversial.
  • Historically, CABG showed modest long-term benefits over medical therapy for heart failure with reduced ejection fraction (HFrEF) prior to recent pharmacological advances.
  • Current evidence indicates revascularization provides no benefit in HFrEF patients managed with modern medical therapy.

Purpose of the Study:

  • To clarify the current role and indications for myocardial revascularization in patients with heart failure and coronary artery disease.
  • To evaluate the effectiveness of PCI versus CABG in the context of contemporary heart failure treatments.
  • To provide guidance on decision-making processes for revascularization in complex HF/CAD cases.

Main Methods:

  • Review and synthesis of existing evidence regarding myocardial revascularization strategies in heart failure patients.
  • Analysis of outcomes based on different revascularization procedures (PCI vs. CABG) and medical therapies.
  • Consideration of patient selection strategies, including viability and ischemia-guided approaches.

Main Results:

  • Revascularization offers no survival or symptomatic benefit for heart failure with reduced ejection fraction patients receiving guideline-directed medical therapy (GDMT).
  • Evidence supporting viability or ischemia-guided selection for revascularization in HF patients is controversial.
  • Optimizing GDMT and device therapy is paramount for all HF patients.

Conclusions:

  • The decision for revascularization in HF patients with CAD should be individualized and discussed by a heart team, considering limited and conflicting evidence.
  • Revascularization is not indicated when HF symptoms persist despite optimal GDMT and device therapy.
  • Consider revascularization only when angina persists despite GDMT and device therapy, with procedure choice based on symptoms, ischemic burden, surgical risk, and coronary anatomy.

Keywords:
Coronary Artery Bypass GraftHeart FailurePercutaneous Coronary InterventionRevascularization

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