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Ghunaim et al. Vessel Plus 2023;7:29 https://dx.doi.org/10.20517/2574-1209.2023.112 Page 3 of 17

Figure 1. Disparities in CAD with reduced LVEF. CABG: Coronary artery bypass grafting; CAD: coronary arterydisease; LVEF: left
ventricular ejection fraction; PCI: percutaneous coronary intervention; SES: socioeconomic status.

cause mortality at a median follow-up of 56 months was comparable between groups (HR 0.86
[95%CI: 0.72-1.04]) . However, at a median of 9.8 years of follow-up, the addition of CABG was associated
[14]
with a lower hazard of all-cause mortality (HR 0.84 [0.73-0.97]), suggesting long-term survival benefits for
CABG vs. medical therapy alone . These late survival benefits were primarily driven by reduced sudden
[15]
death and fatal pump failure events . It is important to note that optimal medical therapy (OMT) for this
[16]
subset of patients has had significant changes in the recent past. During the time of the STICH trial,
angiotensin receptor-neprilysin inhibitor (ARNI) and sodium-glucose co-transporter-2 inhibitor (SGLT2i)
were not yet part of standard OMT [17,18] . Furthermore, the Swedish Coronary Angiography and Angioplasty
registry (SCAAR) evaluated long-term outcomes in patients with ischemic heart failure with LVEF < 50%
[19]
who underwent either PCI or CABG. They also concluded that CABG had a better long-term survival than
PCI. Propensity-matched observational evidence from Ontario, Canada, further found increased rates of
mortality (HR 1.6 [1.3-1.7]) and major adverse cardiovascular events in patients with severely reduced
LVEF who underwent PCI compared to those who underwent CABG at a median follow-up of 5.2 years .
[20]
The New York State propensity-matched registry study (n = 2,126 matched patients) showed similar mid-
term (median follow-up of 2.9 years) survival between second-generation drug-eluting stents and CABG
(HR 1.01 [0.81-1.28]), and an increased hazard of MI (HR 2.16 [1.42-3.28]) and repeat revascularization
[21]
(HR 2.54 [1.88-3.44]), but lower hazard for stroke (HR 0.57 [0.33-0.97]) in the PCI vs. CABG group .
Lastly, recent meta-analytic findings of comparative studies in patients with CAD and LVEF < 40%
(n = 16,191) concluded that revascularization is superior to OMT alone in terms of mortality reduction
(CABG: HR 0.66 [0.61-0.72]; PCI: HR 0.73 [0.62-0.85]), consistent with previously discussed studies, and
[22]
also favored CABG over PCI (HR 0.82 [0.75-0.90]) .

Less invasive surgical approaches may present further opportunities for patient-centered care by reducing
procedural invasiveness. For example, off-pump CABG (OPCAB) may be associated with comparable
outcomes and rates of complete revascularization compared to conventional CABG, although evidence in
this patient population is limited to smaller studies and mostly single-center experiences with limited