Revascularization in multivessel CAD: A functional approach

The primary objective of invasive treatment strategies for multivessel coronary artery disease is complete anatomical revascularization - traditionally considered the strongest predictor of improved clinical outcome in this setting. This concept, however, is being challenged by evidence suggesting that addressing ischemia is the key to reducing mortality, myocardial infarction, and life-limiting angina. As objective evidence of ischemia can be provided by a functional assessment on the basis of fractional flow reserve, the focus of contemporary treatment should arguably shift from anatomical to functional revascularization. Moreover, the decision to revascularize specific lesions should be made after consideration of the degree of myocardial viability, ischemic burden, overall clinical risk, and technical feasibility. Most importantly, however, the revascularization strategy should be tailored to the individual patient and the expertise of the institution, and use contemporary techniques combined with modern pharmacotherapy. This Perspectives article summarizes the data supporting contemporary functional revascularization and its applicability to real-world practice.