冠状动脉疾病(CAD)的负担很大并且越来越大,通常表现为合并症和老年。经皮冠状动脉介入治疗(PCI)或冠状动脉旁路移植术(CABG)可使患者受益,然而,迄今为止,有一半可从血运重建中获益的CAD患者不在试验的资格标准范围内.因此,血运重建手术的选择取决于CAD的解剖结构和复杂性,患者手术风险和合并症,患者的偏好和价值观,和治疗团队的专业知识。最近的美国冠状动脉血运重建指南全面描述了PCI,CABG,或冠心病患者的保守治疗。然而,个人,指南中无法完全捕获具有挑战性的患者陈述。这篇叙述性综述的目的是总结当代临床指南和试验没有充分描述的常见临床情景,以便告知心脏团队成员和受训者细微差别的考虑因素和管理此类病例的可用证据。在这次审查中,我们讨论了超出当前指南范围的临床病例,并总结了评估这些患者冠状动脉血运重建的相关证据.此外,我们强调了基于缺乏研究的知识差距(例如,某些患者群体不合格),研究中代表性不足(例如,妇女和非白人患者的教育不足),和新的激增,微创,和混合技术。我们认为,最终,循证医学,患者偏好和共同决策,和有效的心脏团队沟通是必要的,以最好地管理复杂的CAD演示文稿可能受益于CABG或PCI的血运重建。
The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient\'s preferences and values, and the treating team\'s expertise. The recent American
guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in
guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical
guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current
guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.