🧠 CABG Indications:
✅ Left main coronary artery disease
50% stenosis of left main = automatic CABG
✅ Triple-vessel disease
70% stenosis in all three major vessels (RCA, LAD, LCx)
Especially with ↓ EF or diabetes
✅ 2-vessel disease involving proximal LAD + ↓ EF or diabetes
✅ Failed PCI or restenosis after PCI
✅ High SYNTAX score
Used in cardiology to assess lesion complexity (not tested heavily, but FYI)
🧠 PCI (Stenting) is preferred when:
✅ Single- or dual-vessel disease not involving left main
✅ Low SYNTAX score
✅ STEMI/NSTEMI with culprit lesion
✅ Unable to tolerate surgery (frail, comorbidities)
💡 USMLE Pro Tips:
CABG is not used in acute STEMI unless anatomy requires it or PCI fails
In patients with diabetes + multivessel disease, CABG improves long-term mortality more than PCI
If you see "proximal LAD" or "left main" = think CABG
🫀 Cardio Question:
A 62-year-old man with type 2 diabetes, hypertension, and hyperlipidemia presents with exertional chest pain for the past 3 months. He reports the pain occurs after climbing one flight of stairs and resolves with rest. A stress echocardiogram shows reversible ischemia in the anterior and lateral walls. Cardiac catheterization shows:
80% stenosis of the proximal LAD
75% stenosis of the LCx
70% stenosis of the RCA
What is the best next step in management?
A) PCI with drug-eluting stents
B) CABG
C) Medical therapy alone
D) Repeat stress testing in 6 months
E) Implantable cardioverter-defibrillator (ICD)
Answer: B) CABG
🔍 Why?
This is a classic vignette for CABG over PCI:
✅ Triple-vessel disease
✅ Involves proximal LAD
✅ Patient has diabetes — big NBME keyword
✅ Reversible ischemia on stress testing
🔑 All of these stack the deck toward CABG, which improves long-term survival in diabetics with multivessel coronary disease far more than PCI.
🚫 Why not the other choices?
A) PCI – not preferred in triple-vessel disease + diabetes
C) Medical therapy – ischemia is too severe
D) Repeat stress – not needed; cath already confirms diagnosis
E) ICD – no indication; EF not mentioned, no arrhythmias or VT/VF
