A 52-year-old woman with a 10-year history of type 2 diabetes mellitus, hypertension, and hypercholesterolemia undergoes coronary angiography for stable angina. Angiography reveals 70% stenosis in the left anterior descending artery, 60% stenosis in the left circumflex artery, and 85% stenosis in the right coronary artery with normal left ventricular ejection fraction. What is the most appropriate next step in management?

Explanation

## Management of Multivessel Coronary Artery Disease (CAD) ### Clinical Presentation This patient has stable multivessel CAD (70% LAD, 60% LCx, 85% RCA) with preserved left ventricular function. The decision between PCI and CABG depends on anatomical complexity and comorbidities. ### Anatomical Assessment **Key Point:** The SYNTAX score (Synergy Between PCI With Taxus and Cardiac Surgery) stratifies multivessel CAD complexity: - **Low SYNTAX (≤22):** PCI preferred - **Intermediate SYNTAX (23–32):** PCI or CABG equivalent - **High SYNTAX (>32):** CABG preferred This patient's three-vessel disease with 85% RCA stenosis likely represents **intermediate-to-high SYNTAX** anatomy, favoring CABG. ### Evidence-Based Comparison | Parameter | CABG | PCI (Multivessel) | |-----------|------|-------------------| | **Completeness of revascularization** | Complete (all vessels grafted) | Incomplete (may miss vessels) | | **Restenosis/repeat revascularization** | Lower (~5–10% at 5 yrs) | Higher (~20–30% at 5 yrs) | | **Stroke risk** | 1–3% (perioperative) | <1% | | **Survival (multivessel CAD)** | Superior at 5+ years | Similar short-term | | **Quality of life** | Improved long-term | Improved short-term | **High-Yield:** CABG is the gold standard for multivessel CAD, especially with: - Three-vessel disease - Left main coronary artery involvement - High SYNTAX score (>32) - Diabetes mellitus (as in this case) - Reduced left ventricular function ### Pathophysiology Context Multivessel atherosclerosis reflects systemic endothelial dysfunction and lipid-driven plaque formation across the coronary tree. CABG provides complete revascularization using internal mammary artery (IMA) grafts (superior patency) and saphenous vein grafts, addressing all stenotic lesions in a single procedure. **Clinical Pearl:** Diabetic patients with multivessel CAD derive greater long-term survival benefit from CABG than PCI, likely due to improved graft patency and complete revascularization. **Mnemonic:** **CABG for MVD** = **C**omplete revascularization, **A**void restenosis, **B**etter long-term outcomes, **G**raft durability.