Coronary Artery Bypass Grafting (CABG) Guidelines
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Clinical guidelines on myocardial revascularization have been issued by the following organizations:
Recommendations have been classified in both guidelines according to the level of evidence supporting the usefulness and efficacy of the procedure [1, 2] :
Both ACC/AHA and ESC/EACTS guidelines give a class I recommendation to the use of a Heart Team approach in determining treatment strategy and selection of appropriate revascularization procedure (ie, percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]). The ACC/AHA guidelines define a Heart Team as “a multidisciplinary team composed of an interventional cardiologist and a cardiac surgeon who jointly 1) review the patient’s medical condition and coronary anatomy, 2) determine that PCI and/or CABG are technically feasible and reasonable, and, 3) discusses revascularization options with the patient before a treatment strategy is selected.”
This approach is similar to the tumor board or “supreme court” approach to complex or high-risk cases, or where there are not enough data (gray areas). For instance, use in patients with unprotected left main or complex coronary artery disease (CAD) is recommended. [1] .
On the other hand, the 2014 ESC/EACTS guidelines revised its recommendation from previous guidelines to include the development and use of standardized, evidence-based, and interdisciplinary protocols for low-risk and common scenarios; however, in such cases, revascularization at the time of diagnostic angiography is recommended against in order to allow for full assessment of the optimal treatment strategy. Multidisciplinary systematic evaluation is still required for complex cases. [2]
The Society of Thoracic Surgeons (STS) and SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores are recommended by both guidelines for risk stratification to aid in clinical decision-making. [1, 2]
Both ACC/AHA and ESC/EACTS provide guidance on the use of CABG as an emergency procedure. [1, 2]
ACC/AHA guidelines provide a class I recommendation for CABG in the context of an ST-segment elevation myocardial infarction (STEMI) in cases where PCI has been impossible to perform or has failed and the patient has persistent pain and ischemia threatening a significant area of myocardium despite medical therapy. [1]
Other class I indications for emergency open heart surgery in the setting of STEMI include the following:
Emergency CABG is not recommended in the following cases [1] :
Recommendations for emergency CABG after failed PCI include the following:
Emergency CABG should not be performed after failed PCI in the absence of ischemia or threatened occlusion, or if revascularization is impossible or futile because of target anatomy or a no-reflow state.
For decisions and recommendations on revascularization, the ACC/AHA guidelines, released in 2011, define significant stenosis as ≥70% diameter narrowing (≥50% for left main CAD). Physiological criteria, such as fractional flow reserve ≤0.80, may also be considered significant. In addition, some recommendations use SYNTAX scores as surrogates for the extent and complexity of CAD. [1]
CABG may be performed to improve symptoms and/or improve survival, with the latter generally given greater weight when selecting a procedure. The guidelines note that in discussions of options, the patient should clearly understand the goal of the procedure (symptom relief, improved survival, or both) before a decision is made. [1]
Recommendations for CABG for symptom improvement are as follows [1, 2] :
ACC/AHA and ESC/EACTS recommendations for CABG to improve survival are compared in Table 1, below. [1, 2]
Table 1. Indications for Coronary Artery Bypass Grafting (Open Table in a new window)
Indication
ACC/AHA
ESC/EACT
Left main disease
Class I
Class I
Three-vessel disease with or without proximal LAD artery disease
Class I
Class I
Two-vessel disease with proximal LAD artery disease
Class I
Class I
Two-vessel disease without proximal LAD artery disease
Class IIa (with extensive ischemia)
Class IIb
Single-vessel disease with proximal LAD artery disease
Class IIa (with LIMA for long-term benefit)
Class I
Single-vessel disease without proximal LAD artery disease
Class III—Harmful
Class IIb
LV Dysfunction
Class IIa (EF 35% to 50%)
Class IIb (EF<35%)
Class I (EF<40%)
Survivors of sudden cardiac death with presumed ischemia-mediated VT
Class I
Class I
LAD = left anterior descending (artery); LV = left ventricle; LIMA= left internal mammary artery EF = ejection fraction; VT = ventricular tachycardia
The ACC/AHA recommends CABG over PCI for improved survival in patients with comorbid diabetes mellitus (DM) and multivessel CAD, particularly with use of the left internal mammary artery (LIMA); the recommendation was upgraded from class IIa in the 2011 guidelines to class I in the 2014 guidelines. However, the use of bilateral internal mammary arteries is associated with increased risk of infection and should be considered only when the benefit outweighs the increased risk (class IIb). [1]
In a 2014 update of the guidelines for patients with stable ischemic heart disease (IHD), the American College of Cardiology (ACC)/American Heart Association (AHA)/American Association for Thoracic Surgery (AATS)/Preventive Cardiovascular Nurses Association (PCNA)/Society for Cardiovascular Angiography and Intervention (SCAI)/Society of Thoracic Surgeons (STS) provided the following recommendations for patients with stable IHD and DM [3] :
· A Heart Team approach is beneficial in the evaluation of CABG versus PCI; mortality risk appears to be lower with CABG than with PCI in most patients with DM and complex multivessel disease, but exceptions may be identified
The ESC/EACTS guidelines recommend CABG as the revascularization modality of choice for improved survival in patients with DM and multivessel or complex (SYNTAX Score >22) CAD. However, PCI can be considered as a treatment alternative in diabetic patients with multivessel disease and a low SYNTAX score (≤22). [2]
In the setting of end-stage renal disease, the ACC/AHA consider CABG as reasonable (class IIb recommendations) for the following indications [1] :
CABG should not be performed in patients with end-stage renal disease whose life expectancy is limited because of noncardiac conditions. [1]
The ESC/EACTS guidelines prefer CABG over PCI for patients with multivessel CAD and chronic kidney disease (CKD) when surgical risk is acceptable and life expectancy is longer than 1 year; PCI is preferred for those patients with high surgical risk and/or life expectancy of less than 1 year but may be challenging in those with heavily calcified coronaries. Considerations include delaying CABG until the effects of angiography on renal function have subsided. [2]
The ACC/AHA recommendations for patients with valvular disease are as follows: [1]
The ESC/EATS recommendations include the following [2] :
The ACC/AHA guidelines provide the following recommendations for patients with comorbid carotid artery disease [1] :
The ESC/EACTS guidelines for carotid artery revascularization in CABG patients include the following [2] :
The ESC/EACTS advise that CAS should be considered in patients with any of the following (class IIa):
The ACC/AHA guidelines make the following recommendations for bypass graft conduit selection [1] :
Guidelines on conduit selection from by the Society of Thoracic Surgeons include the following recommendations:
Recommendations for the management of antiplatelet therapy in patients undergoing CABG have been provided by the following organizations:
For preoperative management of antiplatelet therapy, see Table 2, below. [1, 4, 5, 6, 7]
Table 2. Preoperative management of antiplatelet therapy in patients undergoing CABG (Open Table in a new window)
Recommendation
2011 ACC/AHA
2012 ACC/AHA
2014 ACC/AHA
2014 ESC/EACT
2012
STS
Administer aspirin to CABG patients preoperatively
(100 mg to 325 mg daily)
Class I
Class I
(81–325 mg daily)
Class I
(75–160 mg daily)
Class I
In patients at increased risk for bleeding and those who refuse blood transfusion, discontinue aspirin 3-5 days prior to surgery
Class I
Class IIa
For non-urgent CABG, discontinue clopidogrel and ticagrelor for at least 5 days before surgery and prasugrel for at least 7 days to limit blood transfusions
Class I
Class I
Class I
Class I
In patients referred for urgent CABG, discontinue clopidogrel and ticagrelor for at least 24 hours to reduce major bleeding complications
Class I
Class I
In patients referred for urgent CABG, discontinue eptifibatide and tirofiban for at least 2-4 hours and abciximab for at 12 hours
Class I
(Discontinue eptifibatide and tirofiban 4 hours)
Class I
Class I
Anticoagulant therapy: unfractionated heparin; discontinue enozaparin 12-24 hours; discontinue fondaparinux for 24 hours; discontinue bivalirudin for 3 hours
Class I
For postoperative management of antiplatelet therapy, see Table 3, below. [1, 4, 5, 6, 7]
Table 3. Postoperative management of antiplatelet therapy in patients undergoing CABG (Open Table in a new window)
Recommendation
2011 ACC/AHA
2014 ACC/AHA
2014 ESC/EACT
2012
STS
Administer aspirin to CABG patients indefinitely
100 mg to 325 mg daily –
Class I
81–325 mg daily(Only 81 mg with ticagrelor)
Class I
75–160 mg daily
Class I
Class I
Administer clopidogrel or ticagrelor, in addition to aspirin, for 12 months
Class I
Class IIb
Clopidogrel (75 mg daily) is a reasonable alternative in patients intolerant or allergic to aspirin
Class IIa
Class I
In CABG after acute coronary syndromes, restart dual antiplatelet therapy when bleeding risk is diminished.
Class I
Once postoperative bleeding risk is decreased, consider testing of response to antiplatelet drugs, either with
genetic testing or with point-of-care platelet function testing, to optimize antiplatelet drug effect and minimize thrombotic risk to vein grafts
Class IIb
[Guideline] Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011 Dec 6. 124 (23):e652-735. [Medline]. [Full Text].
[Guideline] Authors/Task Force members, Windecker S, Kolh P, Alfonso F, Collet JP, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014 Oct 1. 35 (37):2541-619. [Medline]. [Full Text].
[Guideline] Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014 Nov 4. 130 (19):1749-67. [Medline]. [Full Text].
[Guideline] 2012 Writing Committee Members, Jneid H, Anderson JL, Wright RS, Adams CD, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2012 Aug 14. 126 (7):875-910. [Medline]. [Full Text].
[Guideline] Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 23. 130 (25):e344-426. [Medline]. [Full Text].
[Guideline] Sousa-Uva M, Storey R, Huber K, Falk V, Leite-Moreira AF, Amour J, et al. Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery. Eur Heart J. 2014 Jun 14. 35 (23):1510-4. [Medline]. [Full Text].
[Guideline] Ferraris VA, Saha SP, Oestreich JH, Song HK, Rosengart T, Reece TB, et al. 2012 update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients having cardiac and noncardiac operations. Ann Thorac Surg. 2012 Nov. 94 (5):1761-81. [Medline]. [Full Text].
[Guideline] Aldea GS, Bakaeen FG, Pal J, Fremes S, Head SJ, Sabik J, et al. The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting. Ann Thorac Surg. 2016 Feb. 101 (2):801-9. [Medline]. [Full Text].
Indication
ACC/AHA
ESC/EACT
Left main disease
Class I
Class I
Three-vessel disease with or without proximal LAD artery disease
Class I
Class I
Two-vessel disease with proximal LAD artery disease
Class I
Class I
Two-vessel disease without proximal LAD artery disease
Class IIa (with extensive ischemia)
Class IIb
Single-vessel disease with proximal LAD artery disease
Class IIa (with LIMA for long-term benefit)
Class I
Single-vessel disease without proximal LAD artery disease
Class III—Harmful
Class IIb
LV Dysfunction
Class IIa (EF 35% to 50%)
Class IIb (EF<35%)
Class I (EF<40%)
Survivors of sudden cardiac death with presumed ischemia-mediated VT
Class I
Class I
LAD = left anterior descending (artery); LV = left ventricle; LIMA= left internal mammary artery EF = ejection fraction; VT = ventricular tachycardia
Recommendation
2011 ACC/AHA
2012 ACC/AHA
2014 ACC/AHA
2014 ESC/EACT
2012
STS
Administer aspirin to CABG patients preoperatively
(100 mg to 325 mg daily)
Class I
Class I
(81–325 mg daily)
Class I
(75–160 mg daily)
Class I
In patients at increased risk for bleeding and those who refuse blood transfusion, discontinue aspirin 3-5 days prior to surgery
Class I
Class IIa
For non-urgent CABG, discontinue clopidogrel and ticagrelor for at least 5 days before surgery and prasugrel for at least 7 days to limit blood transfusions
Class I
Class I
Class I
Class I
In patients referred for urgent CABG, discontinue clopidogrel and ticagrelor for at least 24 hours to reduce major bleeding complications
Class I
Class I
In patients referred for urgent CABG, discontinue eptifibatide and tirofiban for at least 2-4 hours and abciximab for at 12 hours
Class I
(Discontinue eptifibatide and tirofiban 4 hours)
Class I
Class I
Anticoagulant therapy: unfractionated heparin; discontinue enozaparin 12-24 hours; discontinue fondaparinux for 24 hours; discontinue bivalirudin for 3 hours
Class I
Recommendation
2011 ACC/AHA
2014 ACC/AHA
2014 ESC/EACT
2012
STS
Administer aspirin to CABG patients indefinitely
100 mg to 325 mg daily –
Class I
81–325 mg daily(Only 81 mg with ticagrelor)
Class I
75–160 mg daily
Class I
Class I
Administer clopidogrel or ticagrelor, in addition to aspirin, for 12 months
Class I
Class IIb
Clopidogrel (75 mg daily) is a reasonable alternative in patients intolerant or allergic to aspirin
Class IIa
Class I
In CABG after acute coronary syndromes, restart dual antiplatelet therapy when bleeding risk is diminished.
Class I
Once postoperative bleeding risk is decreased, consider testing of response to antiplatelet drugs, either with
genetic testing or with point-of-care platelet function testing, to optimize antiplatelet drug effect and minimize thrombotic risk to vein grafts
Class IIb
Walter Tan, MD, MS Associate Professor of Medicine, Wake Forest University School of Medicine; Director of Cardiac Cath Labs, Wake Forest Baptist Medical Center
Walter Tan, MD, MS is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American Heart Association, American Stroke Association, National Stroke Association, Society for Vascular Medicine, Society of Interventional Radiology
Disclosure: Nothing to disclose.
Mariclaire Cloutier Freelance editor, Medscape Drugs & Diseases
Disclosure: Nothing to disclose.
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