Phoenix rising: a credible signal for CABG from ISCHEMIA?

When the writing committee (WC) for the U.S. coronary revascularisation guideline downgraded the recommendation for using coronary artery bypass graft (CABG) surgery to improve survival in patients with multivessel chronic coronary disease (CCD) from Class 1 (“should be done”) in 20111 to Class 2b (“may be reasonable”) in 20212 and placed it on par with the other 2b recommendation (“is uncertain”) for percutaneous coronary intervention (PCI)2, surgeons cried foul3. The original CABG recommendation1 was based on older studies and a meta-analysis from 19944, which suggested that study subjects with three-vessel coronary artery disease had better survival 5 years after CABG than they would have had if they had received medical therapy (MT) alone. The 2011 WC knew that MT in the older trials consisted of aspirin in 26% and beta blockers in 66% of subjects4 but rationalised that it was based on the best evidence at the time. As evidence grew and the concept of guideline-directed medical therapy (GDMT) emerged, the 2021 WC concluded that MT in older studies amounted to almost nothing....