Audience: acute-cardiology, interventional-cardiology and cardiothoracic teams. Evidence reviewed: September 2026.
Key message
In acute coronary syndrome (ACS), culprit treatment and complete revascularisation are related but distinct decisions. CABG should remain in the index-admission pathway when anatomy, diabetes, ventricular dysfunction, mechanical complications or PCI feasibility suggests a prognostic or technical advantage—provided timing balances recurrent-ischaemia and bleeding risks.
Stabilise first, then define the problem
Immediate management follows ACS severity: resuscitation, antithrombotic therapy, urgent angiography and culprit reperfusion when indicated. Cardiogenic shock, ongoing ischaemia, failed PCI or a mechanical complication demands rapid multidisciplinary escalation; the ideal revascularisation mode may differ from that in a stable NSTEMI patient.
Anatomy that should trigger surgical discussion
- Significant left-main disease, especially complex distal bifurcation disease.
- Complex three-vessel disease not amenable to durable complete PCI.
- Diabetes with multivessel coronary disease where long-term evidence favours surgery in suitable patients.
- Need for concomitant valve, aortic or mechanical-complication surgery.
- Failed or complicated PCI with ongoing jeopardised myocardium.
The index-admission Heart Team
| Domain | Questions |
|---|---|
| Clinical stability | Ongoing pain, shock, arrhythmia, heart failure or mechanical complication? |
| Coronary anatomy | Left main, complexity, targets, chronic occlusions, likelihood of complete revascularisation? |
| Myocardium | LV function, infarct territory, viability where genuinely uncertain? |
| Patient factors | Frailty, cognition, renal/pulmonary disease, prior surgery, preferences and rehabilitation potential? |
| Treatment constraints | Recent P2Y12 inhibitor, bleeding, anticoagulation, infection and theatre availability? |
Timing is an individual risk balance
Emergency CABG may be necessary for failed reperfusion, anatomy unsuitable for PCI with ongoing ischaemia, or mechanical complications. In stable patients, surgery is often delayed sufficiently to reduce perioperative bleeding and allow antiplatelet washout, but unnecessary discharge can expose patients to recurrent ischaemia and fragmented decision-making. The plan should state the reason for timing, antithrombotic strategy and triggers for acceleration.
Routine platelet-transfusion or bridging strategies should not be improvised. Follow the current guideline, local surgical protocol and patient-specific thrombotic and bleeding risks. Aspirin is commonly continued, while interruption intervals for P2Y12 inhibitors depend on the agent and urgency.
Communication standard
Document: culprit and residual anatomy; whether PCI achieved stable reperfusion; why CABG, PCI or medical therapy is preferred; estimated surgical and bleeding risk; antiplatelet stop dates; intended timing; contingency plan; and the patient’s informed preference. “For outpatient discussion” is not an adequate plan when prognostically important disease remains untreated.
Selected references
- 2025 ACC/AHA multisociety guideline for acute coronary syndromes.
- 2025 ACS guideline full publication.
- 2023 ESC acute coronary syndromes guideline.
Educational material only. Revascularisation strategy and timing require case-specific Heart Team decisions and current local antithrombotic/surgical protocols.
The Cardiac Compass 