Chronic stable angina revascularization coronary artery bypass grafting

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; John Fani Srour, M.D.; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Coronary Artery Bypass Grafting (CABG) is carried out to prolong life expectancy and improve overall quality of life.

• Prolongation of life has been shown in patients with more than 50% luminal diameter stenosis of the left main coronary artery and in those with impaired left ventricular function (left ventricular ejection fraction less than 40%) and critical, greater than 70% stenosis in all three major coronary arteries or in two arteries, one of which is the proximal left anterior descending artery. The presence of a high-risk result on a noninvasive test also increases the benefit of surgery. Patients with severe left ventricular dysfunction obtain a survival benefit from CABG if the myocardium with impaired contractile function is viable (hibernating myocardium) rather than necrotic.

• The stenotic arteries are bypassed with an internal mammary (arterial) or saphenous vein graft.

• Arterial grafts have excellent long-term patency rates (90% at 10 years), whereas saphenous vein grafts show accelerated atherosclerosis with approximately 50% patency at 10 years.
• The use of internal mammary artery grafts is associated with a 27% reduction in 15-year mortality compared with saphenous vein grafts.
• The left internal mammary artery is most favorable to a graft to the left anterior descending coronary artery and the right internal mammary artery is most applicable to graft to the right coronary artery.
• Patients who require more than two grafts generally receive a combination of arterial and venous grafts.

• Minimally invasive CABG via a smaller thoractomy incision or a thorascopic approach reduces the morbidity and hospital length-of-stay.

• The operative mortality of CABG is about 2%. The steady improvements in perioperative care have been offset by the progressively sicker patients who are referred for this procedure.

• Angina pectoris is relieved in more than 90% of patients who undergo CABG. The recurrence of angina is due to graft stenosis or progression of disease in nongrafted vessels.

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)

Revascularization With PTCA (or Other Catheter-Based Techniques) and CABG in Patients With Stable Angina (DO NOT EDIT)

Class I

"1. CABG for patients with significant left main coronary disease. (Level of Evidence: A)"

"2. CABG for patients with three-vessel disease. The survival benefit is greater in patients with abnormal LV function (ejection fraction less than 50%). (Level of Evidence: A)"

"3. CABG for patients with two-vessel disease with significant proximal left anterior descending CAD and either abnormal LV function (ejection fraction less than 50%) or demonstrable ischemia on noninvasive testing. (Level of Evidence: A)"

"4. PTCA for patients with 2- or 3-vessel disease with significant proximal left anterior descending CAD, who have anatomy suitable for catheter-based therapy, normal LV function, and who do not have treated diabetes.(Level of Evidence: B)"

"5. PTCA or CABG for patients with one- or two-vessel CAD without significant proximal left anterior descending CAD but with a large area of viable myocardium and high-risk criteria on noninvasive testing. (Level of Evidence: B)"

"6. CABG for patients with one- or two-vessel CAD without significant proximal left anterior descending CAD who have survived sudden cardiac death or sustained ventricular tachycardia. (Level of Evidence: C)"

"7. In patients with prior PTCA, CABG or PTCA for recurrent stenosis associated with a large area of viable myocardium and/or high-risk criteria on noninvasive testing. (Level of Evidence: C)"

"8. PTCA or CABG for patients who have not been successfully treated by medical therapy and can undergo revascularization with acceptable risk. (Level of Evidence: B)"

Class III

"1. PTCA or CABG for patients with one- or two-vessel CAD without significant proximal left anterior descending CAD who have mild symptoms that are unlikely due to myocardial ischemia or have not received an adequate trial of medical therapy and

a. Have only a small area of viable myocardium or

b. Have no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)"

"2. PTCA or CABG for patients with borderline coronary stenoses (50% to 60% diameter in locations other than the left main) and no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)"

"3. PTCA or CABG for patients with insignificant coronary stenosis (less than 50% diameter). (Level of Evidence: C)"

"4. PTCA in patients with significant left main CAD who are candidates for CABG. (Level of Evidence: B)"

"5. PTCA is used in these recommendations to indicate PTCA and/or other catheter-based techniques such as stents, atherectomy, and laser therapy."

Class IIa

"1. Repeat CABG for patients with multiple saphenous vein graft stenoses, especially when there is significant stenosis of a graft supplying the left anterior descending coronary artery. PTCA may be appropriate for focal saphenous vein graft lesions or multiple stenoses in poor candidates for re-operative surgery. (Level of Evidence: C)"

"2. PTCA or CABG for patients with one- or two-vessel CAD without significant proximal left anterior descending CAD but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing. (Level of Evidence: B)"

"3. PTCA or CABG for patients with one-vessel disease with significant proximal left anterior descending0 CAD. (Level of Evidence: B)"

Class IIb

"1. Compared with CABG, PTCA for patients with two- or three-vessel disease with significant proximal left anterior descending CAD who have anatomy suitable for catheter-based therapy and who have treated diabetes or abnormal LV function. (Level of Evidence: B)"

"2. PTCA for patients with significant left main coronary disease who are not candidates for CABG. (Level of Evidence: C)"

"3. PTCA for patients with 1- or 2-vessel CAD without significant proximal left anterior descending CAD who have survived sudden cardiac death or sustained ventricular tachycardia. (Level of Evidence: C)"

ESC Guidelines- Revascularization to improve prognosis (DO NOT EDIT)

“

Class I 1. CABG for significant left main CAD or its equivalent (i.e. severe stenosis of ostial/proximal segment of left descending and circumflex coronary arteries). (Level of Evidence: A) 2. CABG for significant proximal stenosis of three major vessels, particularly in those patients with abnormal LV function or with early or extensive reversible ischaemia on functional testing. (Level of Evidence: A) 3. CABG for one- or two-vessel disease with high-grade stenosis of proximal LAD with reversible ischaemia on non-invasive testing. (Level of Evidence: A) 4. CABG for significant disease with impaired LV function and viability demonstrated by non-invasive testing. (Level of Evidence: B) Class IIa 1. CABG for one- or two-vessel CAD without significant proximal LAD stenosis in patients who have survived sudden cardiac death or sustained ventricular tachycardia. (Level of Evidence: B) 2. CABG for significant three-vessel disease in diabetics with reversible ischaemia on functional testing. ((Level of Evidence: C) 3. PCI or CABG for patients with reversible ischaemia on functional testing and evidence of frequent episodes of ischaemia during daily activities. (Level of Evidence: C)

”

ESC Guidelines- Revascularization to improve symptoms (DO NOT EDIT)

“

Class I 1. CABG for multi-vessel disease technically suitable for surgical revascularization in patients with moderate-to-severe symptoms not controlled by medical therapy, in whom risks of surgery do not outweigh potential benefits. (Level of Evidence: A) Class IIa 1. CABG for one-vessel disease technically suitable for surgical revascularization in patients with moderate-to-severe symptoms not controlled by medical therapy, in whom operative risk does not outweigh potential benefit. (Level of Evidence: A) 2. CABG for multi-vessel disease technically suitable for surgical revascularization in patients with mild-to-moderate symptoms which are nonetheless unacceptable to the patient, in whom operative risk does not outweigh potential benefit. (Level of Evidence: A) Class IIb 1. CABG for one-vessel disease technically suitable for surgical revascularization in patients with mild-to-moderate symptoms which are nonetheless unacceptable to the patient, in whom operative risk is not greater than the estimated annual mortality. (Level of Evidence: B)

”

Vote on and Suggest Revisions to the Current Guidelines

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

• The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina