What are the key indications for referring a patient to cardiothoracic surgery for suspected coronary artery disease?

Key indications for referring a patient to cardiothoracic surgery for suspected coronary artery disease (CAD) include:

• Presence of significant CAD demonstrated by coronary angiography, specifically left main stem disease or proximal three-vessel disease, in patients whose symptoms are satisfactorily controlled with optimal medical treatment but who have suitable coronary anatomy for surgery. In such cases, coronary artery bypass grafting (CABG) should be considered.
• Patients with stable angina who have not responded adequately to drug treatment and/or revascularisation may require comprehensive re-evaluation to consider further revascularisation options, including surgical referral.

Referral for surgery is generally considered after detailed anatomical assessment by invasive coronary angiography or high-quality CT coronary angiography has confirmed significant coronary artery stenosis (≥ 70% diameter stenosis in major epicardial arteries or ≥ 50% in the left main coronary artery) and when non-invasive functional imaging or clinical assessment supports the diagnosis of myocardial ischaemia.

Emergency referral to hospital (and potentially surgery) is indicated in acute coronary syndromes (ACS) with ongoing chest pain or ECG changes consistent with STEMI or NSTEMI, but this is managed initially as an emergency rather than elective surgical referral.

Thus, the key elective surgical referral indications for suspected CAD are significant left main or proximal multi-vessel disease confirmed by angiography in patients with stable angina despite optimal medical therapy.

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