IMPORTANCE Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups. OBJECTIVE To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD). EVIDENCE REVIEW A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible. FINDINGS Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX Յ22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies. CONCLUSIONS AND RELEVANCE Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.

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To determine the potential differences in control underlying compensatory and voluntary reach-to-grasp movements the current study compared the kinematic and electromyographic profiles associated with upper limb movement. Postural perturbations were delivered to evoke compensatory reach-to-grasp in ten healthy young adult volunteers while seated on a chair that tilted as an inverted pendulum in the frontal plane. Participants reached to grasp a laterally positioned stable handhold and pulled (or pushed) to return the chair to vertical. The distinguishing characteristic between the two behaviors was the onset latency and speed of movement. Consistent with compensatory balance reactions, the perturbation-evoked reach response was initiated very rapidly (137 vs. 239 ms for voluntary). As well the movement time was shorter, and peak velocity was greater for PERT movements. In spite of the profound differences in timing, the sequence of muscle activity onsets and the order of specific kinematic events were not different between maximum velocity voluntary (VOL) and perturbation-evoked (PERT) reach-to-grasp movements. Peak velocity and grasp aperture occurred prior to hand contact with the target for PERT and VOL movements, and wrist trajectory was influenced by the direction of perturbation relative to the target. To achieve such target specific control for responses initiated within 100 ms of the perturbation, and when characteristics of body movement were unpredictable, the perturbation-evoked movements would need to incorporate sensory cues associated with body movement relative to the target into the earliest aspects of the movement. This suggests reliance on an internal spatial map constructed prior to the onset of perturbation. Parallels in electromyographic and kinematic profiles between compensatory and voluntary reach-to-grasp movements, in spite of temporal differences, lead to the view they are controlled by common neural mechanisms.