It depends on whether the patient falls in the low, intermediate or high risk category based on:
- The severity of the narrowing (we use scores such as modified Duke Score/SYNTAX score etc )
- Heart’s pumping ability( by echocardiography) and
- Presence of other issues such as blood pressure, diabetes and high cholesterol
It also depends on whether patient is stable and the procedure is an elective procedure, or if the patient has presented suddenly with chest pain or breathlessness which drastically alters the strategy.
We generally use both the clinical factors and angiographic picture to asses the final risk status and the treatment strategy for the patient.
National and International guidelines in general advocate the use of revascularization (heart stent or heart bypass) in the presence of high risk features to improve both survival and quality of life.
As mentioned earlier sometimes we also need to do imaging inside blood vessels called IVUS (Intravascular ultrasound) or OCT (Optical Coherence tomography) along with FFR(pressure measurements) to further classify risk and need for stents or bypass surgery.
The CONFIRM registry looked at around 12000 patients and found that patients with intermediate and high-risk scores lived longer if they underwent revascularization (ie heart stents or heart bypass surgery). In another analysis by Mancini et al, in 5000 patients with diabetes and coronary disease, those who undertook bypass or stents in comparison to medical therapy had lower mortality by upto 24%.
Some trials such as COURAGE and BARI 2D did not show a benefit of revascularization as compared to OMT (optimal medical therapy) but there were many limitations to the trials including selection bias etc.
Indeed there are many many reviews and meta-analysis which show that in patients with multiple blockages with or without symptoms and poor blood flow to a large part of the heart muscle (ischemia), undergoing revascularization (ie heart stents or heart bypass) significantly improves survival and quality of life.
