ISBN: 978-1-4731-3093-7 6.3 Invasive procedures The update to the heart failure guideline includes topics where new evidence has emerged since the publication in 2010. A review of new evidence published after 2010 was carried out in order to determine whether any changes to current recommendations where likely to be required. The decision on which topics to include in the update of the guideline was made following consultation of the scope. This section with the exception of coronary revascularisation was not within the scope of the update. For more information on the following aspects of invasive procedures such as cardac transplantation please refer to appendix R in the 2003 guideline. 6.3.1 Coronary revascularisation Coronary artery disease (CAD) and heart failure often coexist and a majority of people with heart failure and reduced ejection fraction (HFREF) in the UK will have an ischaemic aetiology149 . Myocardial ischaemia is therefore often an important additional consideration in the management of people with heart failure. Concomitant severe CAD may warrant consideration for revascularisation with coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) in view of uncontrolled angina despite medical therapy, evidence of substantial myocardial ischaemia and viability or while undergoing valve intervention. Thus it might appear logical that coronary revascularisation, undertaken either surgically with CABG, or percutaneously with angioplasty, might result in improved outcomes when compared with medical therapy alone. However, the presence of left ventricular systolic dysfunction (LVSD) significantly increases the risk of both surgical and percutaneous revascularisation 373 and, if severe, may contraindicate CABG surgery altogether. Historically, however, there has only been anecdotal evidence of improvement in symptoms or left ventricular function following revascularisation in people with heart failure in the absence of the above special indications. 