Coronary Artery Bypass or Percutaneous Intervention in Chronic Coronary Syndrome: A Focused Review of the 2024 European Society of Cardiology Guidelines

In this review we summarise the 2024 ESC guideline recommendations comparing the role of PCI and CABG in chronic coronary syndromes (CCS), highlighting common clinical scenarios, evidence levels, and decision-making principles. The guidelines support CABG as the preferred strategy for left main and complex multivessel disease, particularly among patients with diabetes mellitus and/or left ventricular dysfunction. PCI provides comparable survival outcomes in low-anatomical-complexity disease (e.g., low SYNTAX score, significant left main or three-vessel disease in non-diabetics). For single- or double-vessel disease involving the proximal left anterior descending artery (LAD), both PCI and CABG are equally recommended for prognostic benefit, whereas isolated non-LAD disease may be managed with PCI for symptom relief. In heart failure patients (EF ≤ 35%) with viable myocardium, CABG improves long-term survival, while PCI may be considered if surgery is contraindicated. The guidelines reinforce that the choice between CABG and PCI should be individualised through a multidisciplinary Heart Team approach. In short, CABG is favoured for complex anatomy, diabetic, or LV-dysfunction cases, while PCI is appropriate for lower-complex anatomy or in high surgical risk.