1. Should she be on medication now? Yes, she should be on aspirin, ace inhibitor and a beta blocker if tolerated. she may also need nitrates and a diurtetic. cholesterol should be lowered and diabetes tightly controlled.
2. Is bypass a better solution for her situation? The solution to her problem depends on how much more heart muscle is at risk. Given that she has already had extensive damage to her heart muscle with an EF of 25 % it may be prudent to have a PET scan performed to determine if there are areas of ischemia or hibernating myocardium that will benefit from surgery. In general, CABG is a better alternative to multiple vessel angioplasty in a diabetic with a reduced ejection fraction.
3. What are the risks for each? Tis will need to be discussed with the individuals performing each of these procedures as rates vary. At Cleveland Clinic, operative mortality for all comers is less than 1%
4. What information tells me that her doctor's institution is experienced? this is usually determined by the volume for example CCF performs more than 4000 surgeries per year. Many institutions may only perform several hundred. Years of experience. You also need to assess ancillary services ( if a problem arises).