Coronary revascularization for patients with unprotected left main coronary artery disease: evidence, guidelines, and judgment! Making clinical decisions in 2009.
The current clinical practice guidelines categorize the use of coronary artery bypass graft (CABG) surgery for revascularization of patients with unprotected left main coronary artery disease (ULMCAD) as a class IA recommendation while it categorize the use of percutaneous coronary interventions (PCI) as a class III recommendation. The evidence underlying these recommendations is weak and out dated. The purpose of this review is to critically reevaluate current state-of-the-art with respect to revascularization of patients with ULMCAD who are acceptable surgical candidates. In doing so we will highlight the divergence between practice guidelines and patient-centered clinical decision-making; critically appraise the "evidence" underlying the current practice guidelines; review the emerging data regarding utility of CABG versus PCI in these patients; and finally discuss the elements of a contemporary approach to clinical decision-making in light of the current state of knowledge.
Department of Medicine, Division of Cardiology, Weill Medical College of Cornell University, New York, New York 10021, USA. ism9003@med.cornell.edu
Issam D
ID
Moussa
S Chiu
SC
Wong
Ted
T
Feldman
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation; D002983:Clinical Competence; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D019317:Evidence-Based Medicine; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D012042:Registries; D018570:Risk Assessment; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome