Referral for surgery

Symptomatic disease involving all three coronary arteries which is uncontrolled by medical therapy will be improved by coronary artery bypass grafting. Prognosis is unaltered unless there is coexisting left ventricular dysfunction (ejection fraction below 40 per cent). The increasing use of left internal mammary grafts may alter this balance in the future, as long-term results are better when this conduit can be used.

Left main stem stenosis above 30 per cent carries an adverse prognosis (1 year mortality of 20 per cent) which benefits from surgical revascularization. Proximal left anterior descending coronary artery stenosis above 70 per cent is a high-risk lesion, and there is little to choose between angioplasty and left internal mammary artery grafting. Stenting may prove more advantageous in the future.

Unstable multivessel coronary disease, which does not settle medically, merits early investigation and referral for surgery if other revascularization techniques are not applicable.

Patients with symptomatic disease of one or two vessels, which is unacceptable despite adequate medical therapy and unsuitable for percutaneous transluminal coronary angioplasty/stenting (or a failed attempt at these procedures), should be referred for surgical revascularization. The patient needs to understand the individual risks and benefits; mortality benefits are not seen, although there are good symptomatic benefits.

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