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

This review summarises the 2024 ESC guidelines on coronary revascularisation in chronic coronary syndromes (CCS), comparing the roles of CABG and PCI across various clinical scenarios. Based on the best available evidence, the recommendations are defined as class I (should be performed), IIa (reasonable to perform), IIb (may be considered), and III (should not be performed). CABG remains the preferred strategy for left main and complex multivessel disease, particularly in patients with diabetes mellitus, owing to its superior long-term outcomes. PCI offers comparable survival in non-diabetic patients with low SYNTAX scores and preserved ventricular function. For single- or double-vessel disease involving the proximal left anterior descending artery (LAD), both PCI or CABG provide prognostic benefit, while isolated non-LAD disease may be managed with PCI for symptoms not controlled by medical therapy. In ischemic heart failure patients (ejection fraction ≤35%) with viable myocardium, CABG improves survival, whereas PCI is an alternative if the surgical risk is prohibitive. Overall, the guidelines emphasise that revascularisation decisions should be individualised through a multidisciplinary Heart Team approach integrating evidence, available expertise, and patient preferences.