Abstract
Recent updates to clinical guidelines have downgraded the recommendations for coronary artery bypass grafting (CABG) in stable coronary artery disease (CAD), emphasizing optimal medical therapy (OMT) and selective revascularization based on symptom burden and risk assessment. The ISCHEMIA trial played a pivotal role in this shift, suggesting no significant survival benefit of an initial invasive approach compared to OMT. However, the limitations of the trial, including patient selection bias, exclusion of high-risk populations, and short follow-up duration, warrant critical reassessment of its applicability to contemporary practice. Despite these changes, substantial evidence supports the long-term superiority of CABG to OMT in reducing mortality and major adverse cardiovascular events, particularly in patients with multivessel disease, diabetes, or left ventricular dysfunction. In addition, recent advancements in surgical techniques, such as arterial grafting, off-pump procedures, minimally invasive approaches, and hybrid coronary revascularization, have improved patient outcomes while minimizing procedural risks. Given the limitations of recent guideline modifications and the ongoing evolution of CABG techniques, a balanced approach is required. Future guidelines should incorporate emerging evidence reflecting CABG’s long-term benefits of CABG and technological advancements. An individualized, patient-centered strategy guided by a multidisciplinary heart team is crucial for determining the optimal revascularization approach. This review critically examines the evolving role of CABG in CAD management, addressing the controversies surrounding recent guideline updates and advocating for the integration of new surgical innovations into future recommendations to ensure optimal patient outcomes.
