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The 2018 ESC/EACTS guidelines on myocardial revascularization reflect the joint effort of the European Society of Cardiology (ESC) and the European Association of Cardiothoracic Surgery (EACTS) to provide up-To-date recommendations that are both evidence-based and clinically meaningful. Although the field of myocardial revascularization represents one of the best studied therapeutic technical interventions in medicine with >20 randomized clinical trials (RCT) comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) enrolling approximately 15 000 patients, there remain areas of controversy owing to imperfect or incomplete data that have accumulated over time. One of the major points of discussion surround the issue of choosing between the revascularization strategies based on clinically relevant subsets. The appropriate treatment allocation among patients with left main and coronary artery disease (CAD) at estimated low surgical risk remains a complex decision process. It is best achieved in the context of the local Heart Team taking into consideration the operative risk as calculated by established risk scores, the complexity of the underlying CAD, intra-and extracardiac factors that may favour one revascularization technique over another as well as local expertise. The 2018 ESC/EACTS guidelines on myocardial revascularization recommend the use of the STS score (Class IB) or EuroSCORE II (IIb B) to estimate in-hospital CABG-related mortality,1-3 the calculation of the Syntax score (Class IB) to assess anatomical complexity as well as the long-Term risk of mortality and morbidity after PCI,4-9 and emphasize the importance to achieve complete revascularization (Class IIa B) when considering the revascularization options.10-13 In the absence of an accepted cut-off to define low surgical mortality, the 2018 ESC/EACTS guidelines advise individual decision taking and refer to the estimated risk that has been reported in major trial comparing PCI and CABG. A table to inform the reader is provide in Chapter of the guideline document.14 The stratification of guideline recommendations between CABG and PCI in patients with stable multivessel CAD according to anatomical complexity with use of the SYNTAX score groups, diabetes, and left main disease was introduced in the 2010 ESC/EACTS Guidelines on Myocardial Revascularization15 and maintained in the 2014 version.16 Of note, the ACCF/AHA/SCAI 2011 guideline for PCIs17 and American College of Cardiology (ACC)/AATS/AHA/ ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria18 have embraced the same criteria for stratification of treatment decisions on CABG vs. PCI. Here, we will review the rationale and new evidence in support of this stratification scheme (Take home figure).We also point to the lack of acceptable alternative stratification systems since none of them have been investigated in prospective studies. This article is a companion article to the 2018 ESC/EACTS guidelines on myocardial revascularization expanding on details that are introduced in the chapter revascularization in stable CAD.14.

Original publication




Journal article


European Heart Journal

Publication Date





204 - 212