PCI to improve survival should not be performed in stable patients with significant (>50% diameter steno- sis) unprotected left main CAD who have unfavorable Table 2. Revascularization to Improve Survival Compared With Medical Therapy Anatomic Setting COR LOE References UPLM or complex CAD CABG and PCI I Heart Team approach recommended C 302 304 CABG and PCI IIa Calculation of the STS and SYNTAX scores B 301, 302, 305 310 UPLM* CABG I B 312 318 PCI IIa For SIHD when both of the following are present Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (eg, a low SYNTAX score of 22, ostial or trunk left main CAD) Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality 5%) IIa For UA/NSTEMI if not a CABG candidate B 301, 324 327, 332, 333, 335 337 IIa For STEMI when distal coronary flow is TIMI flow grade 3 and PCI can be performed more rapidly and safely than CABG IIb For SIHD when both of the following are present Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and intermediate to high likelihood of good long-term outcome (eg, low-intermediate SYNTAX score of 33, bifurcation left main CAD) Clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate-severe COPD, disability from prior stroke, or prior cardiac surgery; STS-predicted risk of operative mortality 2%) III: Harm For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG 3-vessel disease with or without proximal LAD artery disease* IIa It is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD (eg, SYNTAX 22) who are good candidates for CABG 2-vessel disease with proximal LAD artery disease* 2-vessel disease without proximal LAD artery disease* CABG IIa With extensive ischemia B 348 351 IIb Of uncertain benefit without extensive ischemia C 343 1-vessel proximal LAD artery disease CABG IIa With LIMA for long-term benefit B 87, 88, 318, 343 PCI IIb Of uncertain benefit B 314,341, 343, 370 1-vessel disease without proximal LAD artery involvement LV dysfunction CABG IIb EF 35% without significant left main CAD B 318, 352 356, 371, 372 PCI Insufficient data N/A Survivors of sudden cardiac death with presumed ischemia-mediated VT PCI I C 345 No anatomic or physiological criteria for revascularization *In patients with multivessel disease who also have diabetes, it is reasonable to choose CABG (with LIMA) over PCI350,362 369 (Class IIa/LOE: B). 