br Acknowledgments This work is supported by grants from the

Acknowledgments This work is supported by grants from the Singapore National Medical Research Council (R-713-000-181-511) and the Ministry of Education (R-713-000-169-112) and by the National Research Foundation Singapore and the Singapore Ministry of Education under its Research Centres of Excellence initiative. The authors declare no competing financial interests.
INTRODUCTION AND COMMENTARY ON THE METHODOLOGY The Spanish Society of Cardiology endorses the clinical practice guidelines (CPG) published by the European Society of Cardiology (ESC). As part of this Pyridoxal isonicotinoyl hydrazone policy, ESC guidelines are translated into Spanish and published in the online version of Revista Española de Cardiología, with the aim of increasing their accessibility and facilitating their implementation. The translated articles are accompanied by an editorial authored by a panel of Spanish experts that highlights the most important content of each CPG document, details changes and innovations introduced since the previous edition, and discusses the more contentious aspects and possible limitations. The editorial also seeks to evaluate and adapt the recommendations to the context of health care organization and clinical practice in Spain. The latest ESC guidelines for myocardial revascularization1 update the previous CPG published in 2014. It should be noted that a major effort has been made to maintain coherence with previous guidelines.
DIAGNOSTIC TOOLS TO GUIDE MYOCARDIAL REVASCULARIZATION
PROCESS FOR DECISION-MAKING AND PATIENT INFORMATION For a number of reasons, fewer coronary artery bypass grafting (CABG) procedures are performed in Spain than in comparable countries, which is reflected in a lower rate of CABG relative to percutaneous coronary intervention (PCI), according to data from the Organisation for Economic Co-operation and Development.
REVASCULARIZATION FOR STABLE CORONARY ARTERY DISEASE Compared with the previous guidelines,2 the new guidelines give less weight to the EuroSCORE II in the prediction of surgical mortality (IIa B in 2014 vs IIb B in 2018), whereas the STS and SYNTAX scores maintain a class I B recommendation. The logistic EuroSCORE and other scores are no longer considered, and the use of the SYNTAX-II score is not recommended. The ESC Task Force members acknowledge the major limitations of the SYNTAX score, but nonetheless still regard thorax as a basic tool in the choice of revascularization method, a conclusion supported by data from a recent collaborative individual patient pooled analysis of randomized trials. To date, only 1 study has compared CABG and PCI specifically in relation to the SYNTAX score. The new guidelines reduce the left ventricular ejection fraction (LVEF) cutoff for indicating revascularization in patients with multivessel disease and documented ischemia; the cutoff was previously ≤ 40% and is now ≤ 35% (I A). The new guidelines add the possibility of revascularization of lesions with FFR < 0.75 (I B). This section of the CPG document addresses the controversial issue of the possible placebo effect of PCI, indicated by the ORBITA study. The Task Force members conclude that, despite its elegant design, the ORBITA study has major limitations that make it unsuitable for guiding changes to clinical practice. Nevertheless, the ORBITA study underlines the importance of optimal medical treatment for patients with stable CAD. The new ESC guidelines incorporate data from a network meta-analysis of 100 studies confirming that new-generation drug-eluting stents (DES) improve survival compared with medical treatment, although this has not been demonstrated in any individual study.
REVASCULARIZATION IN NON–ST-ELEVATION ACUTE CORONARY SYNDROME The invasive strategy remains the standard treatment for most patients with non–ST-segment elevation acute coronary syndrome (NSTEACS). The early invasive strategy (intervention in the first 24hours) is recommended for most NSTEACS patients, including those with elevated troponins, repolarization changes, or a GRACE score> 140. The debate about the basis for intervention within 24hours is an old one, and this strategy has well-known logistic and procedural implications that may significantly contribute to its incomplete implementation in Spain. Therefore, in Spain, the decision on whether to use the early invasive strategy should be informed by consideration of regional health care organization and the type of hospital to which the patient is admitted.