Intensive Optimal Medical Therapy (OMT) + Close Surveillance, with functional reserve verification
ISCHEMIA demonstrated that in asymptomatic/stable CAD with preserved EF and non-LMCA disease, initial invasive strategy does not reduce all-cause mortality over aggressive medical therapy.
"Have we confirmed functional ischemia with FFR/iFR or stress imaging before committing to bypass on anatomical angiogram alone?"
High aerobic fitness and normal EF often signify established robust collateral microvascular circulation.
"Given my preserved LVEF (55%) and absence of Left Main disease, does my case align with the ISCHEMIA trial cohort managed safely with OMT?"
Trial evidence shows no survival difference between invasive vs medical management under these baseline metrics.
"What is my calculated STS / EuroSCORE II operative mortality and stroke risk compared to the annual risk under optimal medical therapy?"
Elective CABG carries a 1-2% baseline procedural risk that must be offset by proven long-term life extension.
"What specific target LDL-C (<55 mg/dL) and antiplatelet regimen will be used to stabilize calcified and fibrous plaques if we trial OMT first?"
Modern statin + PCSK9 inhibitor + aspirin therapy drives plaque stabilization and halts event progression.