indications for coronary angioplasty or surgery

Last edited 11/2019

Possible indications include:

• angina refractory to medical therapy
• triple vessel disease - the more vessels involved the more likely that surgery is to be indicated
• left main stem coronary stenosis

A strong indicator that angioplasty or surgery may be required is also an ST depression of more than 2 mm, or the development of hypotension, on a mild exercise ECG. This indicates a high risk of triple or left main stem coronary disease.

NICE state with respect to stable angina:

• people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment
• consider revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI]) for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment
  • offer coronary angiography to guide treatment strategy for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment. Additional non-invasive or invasive functional testing may be required to evaluate angiographic findings and guide treatment decisions
    
    
  • offer CABG to people with stable angina and suitable coronary anatomy when:
    • their symptoms are not satisfactorily controlled with optimal medical treatment and
    • revascularisation is considered appropriate and
    • PCI is not appropriate
      
      
  • offer PCI to people with stable angina and suitable coronary anatomy when:
    • their symptoms are not satisfactorily controlled with optimal medical treatment and
    • revascularisation is considered appropriate and
    • CABG is not appropriate
      
      
  • when either procedure would be appropriate, explain to the person the risks and benefits of PCI and CABG for people with anatomically less complex disease whose symptoms are not satisfactorily controlled with optimal medical treatment. If the person does not express a preference, take account of the evidence that suggests that PCI may be the more cost-effective procedure in selecting the course of treatment
    
    
  • When either procedure would be appropriate, take into account the potential survival advantage of CABG over PCI for people with multivessel disease whose symptoms are not satisfactorily controlled with optimal medical treatment and who:
    • have diabetes or
    • are over 65 years or
    • have anatomically complex three-vessel disease, with or without involvement of the left main stem
      
      
  • when either revascularisation procedure is appropriate, explain to the person:
    • the main purpose of revascularisation is to improve the symptoms of stable angina
    • CABG and PCI are effective in relieving symptoms
    • repeat revascularisation may be necessary after either CABG or PCI and the rate is lower after CABG
    • stroke is uncommon after either CABG or PCI, and the incidence is similar between the two procedures
    • there is a potential survival advantage with CABG for some people with multivessel disease

     

Reference:

• 1) NICE (August 2016). Stable angina.