Preamble
The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.
The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice.
Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.
In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.
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The Class of Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate if the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.Table 1Applying classification of recommendations and level of evidence
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A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. ∗Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline-recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines.
Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.
The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding the care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.
Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient’s active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, where the benefit-to-risk ratio may be lower.
The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all such current relationships, as well as those existing 12 months previously. In December 2009, the ACCF and AHA implemented a new policy for relationships with industry and other entities (RWI) that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 for the ACCF/AHA definition of relevance). These statements are reviewed by the Task Force and all members during each conference call and meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members are not permitted to write, and must rescue themselves from voting on, any recommendation or section to which their RWI apply. Members who recused themselves from voting are indicated in the list of writing committee members, and section recusals are noted in Appendix 1. Authors’ and peer reviewers’ RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, writing committee members’ comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at www.cardiosource.org/ACC/About-ACC/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of the writing committee was supported exclusively by the ACCF and AHA without commercial support. Writing committee members volunteered their time for this activity.
In an effort to maintain relevance at the point of care for practicing physicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, evidence tables (with references linked to abstracts in PubMed) have been added.
In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.
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It is noteworthy that the ACCF/AHA guidelines are cited as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA.
Alice K. Jacobs, MD, FACC, FAHA, Chair, ACCF/AHA Task Force on Practice Guidelines
1. Introduction
1.1 Methodology and Evidence Review
Whenever possible, the recommendations listed in this document are evidence based. Articles reviewed in this guideline revision covered evidence from the past 10 years through January 2011, as well as selected other references through April 2011. Searches were limited to studies, reviews, and evidence conducted in human subjects that were published in English. Key search words included but were not limited to: analgesia, anastomotic techniques, antiplatelet agents, automated proximal clampless anastomosis device, asymptomatic ischemia, Cardica C-port, cost effectiveness, depressed left ventricular (LV) function, distal anastomotic techniques, direct proximal anastomosis on aorta, distal anastomotic devices, emergency coronary artery bypass graft (CABG) and ST-elevation myocardial infarction (STEMI), heart failure, interrupted sutures, LV systolic dysfunction, magnetic connectors, PAS-Port automated proximal clampless anastomotic device, patency, proximal connectors, renal disease, sequential anastomosis, sternotomy, symmetry connector, symptomatic ischemia, proximal connectors, sequential anastomosis, T grafts, thoracotomy, U-clips, Ventrica Magnetic Vascular Port system, Y grafts. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. References selected and published in this document are representative but not all-inclusive.
The guideline is focused on the safe, appropriate, and efficacious performance of CABG. The STEMI, percutaneous coronary intervention (PCI), and CABG guidelines were written concurrently, with additional collaboration from the Stable Ischemic Heart Disease (SIHD) guideline writing committee. This allowed greater collaboration among the different writing committees on topics such as PCI in STEMI and revascularization strategies in patients with coronary artery disease (CAD) (including unprotected left main PCI, multivessel disease revascularization, and hybrid procedures).
In accordance with the direction of the Task Force and feedback from readers, in this iteration of the guideline, the amount of text has been shortened, and emphasis has been placed on summary statements rather than detailed discussion of numerous individual trials. Online supplemental evidence and summary tables have been created to document the studies and data considered for new or changed guideline recommendations.
Because the executive summary contains only the recommendations, the reader is encouraged to consult the full-text guideline
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for additional detail on the recommendations and guidance on the care of the patient undergoing CABG.- Hillis L.D.
- Smith P.K.
- Anderson J.L.
- 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.
J Am Coll Cardiol. 2011; (published online before print November 7, 2011, doi:10.1016/j.jacc.2011.08.009. Accessed November 7, 2011)
1.2 Organization of the Writing Committee
The committee was composed of acknowledged experts in CABG, interventional cardiology, general cardiology, and cardiovascular anesthesiology. The committee included representatives from the ACCF, AHA, American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons (STS).
1.3 Document Review and Approval
This document was reviewed by 2 official reviewers, each nominated by both the ACCF and the AHA, as well as 1 reviewer each from the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and STS, as well as members from the ACCF/AHA Task Force on Data Standards, ACCF/AHA Task Force on Performance Measures, ACCF Surgeons’ Scientific Council, ACCF Interventional Scientific Council, and Southern Thoracic Surgical Association. All information on reviewers’ RWIs was distributed to the writing committee and is published in this document (Appendix 2. This document was approved for publication by the governing bodies of the ACCF and the AHA and endorsed by the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and STS.
2. Procedural Considerations: Recommendations
2.1 Anesthetic Considerations
Class I
- 1.Anesthetic management directed toward early postoperative extubation and accelerated recovery of low- to medium-risk patients undergoing uncomplicated CABG is recommended.5,6,7(Level of Evidence: B)
- 2.Multidisciplinary efforts are indicated to ensure an optimal level of analgesia and patient comfort throughout the perioperative period.8,9,10,11,12(Level of Evidence: B)
- 3.Efforts are recommended to improve interdisciplinary communication and patient safety in the perioperative environment (eg, formalized checklist-guided multidisciplinary communication).13,14,15,16(Level of Evidence: B)
- 4.A fellowship-trained cardiac anesthesiologist (or experienced board-certified practitioner) credentialed in the use of perioperative transesophageal echocardiography is recommended to provide or supervise anesthetic care of patients who are considered to be at high risk.17,18,19(Level of Evidence: C)
Class IIa
Class IIb
Class III: Harm
- 1.Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG.27,28(Level of Evidence: B)
- 2.Routine use of early extubation strategies in facilities with limited backup for airway emergencies or advanced respiratory support is potentially harmful. (Level of Evidence: C)
2.2 Bypass Graft Conduit
Class I
Class IIa
- 1.The right internal mammary artery is probably indicated to bypass the LAD artery when the LIMA is unavailable or unsuitable as a bypass conduit. (Level of Evidence: C)
- 2.When anatomically and clinically suitable, use of a second internal mammary artery to graft the left circumflex or right coronary artery (when critically stenosed and perfusing LV myocardium) is reasonable to improve the likelihood of survival and to decrease reintervention.33,34,35,36,37(Level of Evidence: B)
Class IIb
- 1.Complete arterial revascularization may be reasonable in patients less than or equal to 60 years of age with few or no comorbidities. (Level of Evidence: C)
- 2.Arterial grafting of the right coronary artery may be reasonable when a critical (≥90%) stenosis is present.32,36,38(Level of Evidence: B)
- 3.Use of a radial artery graft may be reasonable when grafting left-sided coronary arteries with severe stenoses (>70%) and right-sided arteries with critical stenoses (≥90%) that perfuse LV myocardium.39,40,41,42,43,44(Level of Evidence: B)
Class III: Harm
- 1.An arterial graft should not be used to bypass the right coronary artery with less than a critical stenosis (<90%).32(Level of Evidence: C)
2.3 Intraoperative Transesophageal Echocardiography
Class I
- 1.Intraoperative transesophageal echocardiography should be performed for evaluation of acute, persistent, and life-threatening hemodynamic disturbances that have not responded to treatment.45,46(Level of Evidence: B)
- 2.Intraoperative transesophageal echocardiography should be performed in patients undergoing concomitant valvular surgery.45,47(Level of Evidence: B)
Class IIa
2.4 Preconditioning/Management of Myocardial Ischemia
Class I
- 1.Management targeted at optimizing the determinants of coronary arterial perfusion (eg, heart rate, diastolic or mean arterial pressure, and right ventricular or LV end-diastolic pressure) is recommended to reduce the risk of perioperative myocardial ischemia and infarction.54,55,56,57,
- Gibbons R.J.
- Balady G.J.
- Bricker J.T.
- et al.
ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) [published correction appears in J Am Coll Cardiol. 2006;48:1731].J Am Coll Cardiol. 2002; 40: 1531-154058(Level of Evidence: B)
Class IIa
Class IIb
- 1.The effectiveness of prophylactic pharmacological therapies or controlled reperfusion strategies aimed at inducing preconditioning or attenuating the adverse consequences of myocardial reperfusion injury or surgically induced systemic inflammation is uncertain.63,64,65,66,67,68,69,70(Level of Evidence: A)
- 2.Mechanical preconditioning might be considered to reduce the risk of perioperative myocardial ischemia and infarction in patients undergoing off-pump CABG.71,72,73(Level of Evidence: B)
- 3.Remote ischemic preconditioning strategies using peripheral-extremity occlusion/reperfusion might be considered to attenuate the adverse consequences of myocardial reperfusion injury.74,75,76(Level of Evidence: B)
- 4.The effectiveness of postconditioning strategies to attenuate the adverse consequences of myocardial reperfusion injury is uncertain.77,78(Level of Evidence: C)
2.5 Clinical Subsets
2.5.1 CABG in Patients With Acute Myocardial Infarction
Class I
- 1.Emergency CABG is recommended in patients with acute myocardial infarction (MI) in whom (1) primary PCI has failed or cannot be performed, (2) coronary anatomy is suitable for CABG, and (3) persistent ischemia of a significant area of myocardium at rest and/or hemodynamic instability refractory to nonsurgical therapy is present.79,80,
- Chiu F.C.
- Chang S.N.
- Lin J.W.
- et al.
Coronary artery bypass graft surgery provides better survival in patients with acute coronary syndrome or ST-segment elevation myocardial infarction experiencing cardiogenic shock after percutaneous coronary intervention: a propensity score analysis.J Thorac Cardiovasc Surg. 2009; 138: 1326-133081,82,83(Level of Evidence: B) - 2.Emergency CABG is recommended in patients undergoing surgical repair of a postinfarction mechanical complication of MI, such as ventricular septal rupture, mitral valve insufficiency because of papillary muscle infarction and/or rupture, or free wall rupture.84,85,86,87,88(Level of Evidence: B)
- 3.Emergency CABG is recommended in patients with cardiogenic shock and who are suitable for CABG irrespective of the time interval from MI to onset of shock and time from MI to CABG.82,89,90,91(Level of Evidence: B)
- White H.D.
- Assmann S.F.
- Sanborn T.A.
- et al.
Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial.Circulation. 2005; 112: 1992-2001 - 4.Emergency CABG is recommended in patients with life-threatening ventricular arrhythmias (believed to be ischemic in origin) in the presence of left main stenosis greater than or equal to 50% and/or 3-vessel CAD.92(Level of Evidence: C)
Class IIa
- 1.The use of CABG is reasonable as a revascularization strategy in patients with multivessel CAD with recurrent angina or MI within the first 48 hours of STEMI presentation as an alternative to a more delayed strategy.79,81,83,93(Level of Evidence: B)
- Parikh S.V.
- de Lemos J.A.
- Jessen M.E.
- et al.
Timing of in-hospital coronary artery bypass graft surgery for non-ST-segment elevation myocardial infarction patients results from the National Cardiovascular Data Registry ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines).J Am Coll Cardiol Intv. 2010; 3: 419-427 - 2.Early revascularization with PCI or CABG is reasonable for selected patients greater than 75 years of age with ST-segment elevation or left bundle branch block who are suitable for revascularization irrespective of the time interval from MI to onset of shock.94,95,96,97,98(Level of Evidence: B)
Class III: Harm
- 1.Emergency CABG should not be performed in patients with persistent angina and a small area of viable myocardium who are stable hemodynamically. (Level of Evidence: C)
- 2.Emergency CABG should not be performed in patients with no-reflow (successful epicardial reperfusion with unsuccessful microvascular reperfusion). (Level of Evidence: C)
2.5.2 Life-Threatening Ventricular Arrhythmias
Class I
- 1.CABG is recommended in patients with resuscitated sudden cardiac death or sustained ventricular tachycardia thought to be caused by significant CAD (≥50% stenosis of left main coronary artery and/or ≥70% stenosis of 1, 2, or all 3 epicardial coronary arteries) and resultant myocardial ischemia.92,99,100(Level of Evidence: B)
Class III: Harm
- 1.CABG should not be performed in patients with ventricular tachycardia with scar and no evidence of ischemia. (Level of Evidence: C)
2.5.3 Emergency CABG After Failed PCI
Class I
- 1.Emergency CABG is recommended after failed PCI in the presence of ongoing ischemia or threatened occlusion with substantial myocardium at risk.101,102(Level of Evidence: B)
- 2.Emergency CABG is recommended after failed PCI for hemodynamic compromise in patients without impairment of the coagulation system and without a previous sternotomy.101,103,104(Level of Evidence: B)
Class IIa
- 1.Emergency CABG is reasonable after failed PCI for retrieval of a foreign body (most likely a fractured guidewire or stent) in a crucial anatomic location. (Level of Evidence: C)
- 2.Emergency CABG can be beneficial after failed PCI for hemodynamic compromise in patients with impairment of the coagulation system and without previous sternotomy. (Level of Evidence: C)
Class IIb
- 1.Emergency CABG might be considered after failed PCI for hemodynamic compromise in patients with previous sternotomy. (Level of Evidence: C)
Class III: Harm
- 1.Emergency CABG should not be performed after failed PCI in the absence of ischemia or threatened occlusion. (Level of Evidence: C)
- 2.Emergency CABG should not be performed after failed PCI if revascularization is impossible because of target anatomy or a no-reflow state. (Level of Evidence: C)
2.5.4 CABG in Association With Other Cardiac Procedures
Class I
- 1.CABG is recommended in patients undergoing noncoronary cardiac surgery with greater than or equal to 50% luminal diameter narrowing of the left main coronary artery or greater than or equal to 70% luminal diameter narrowing of other major coronary arteries. (Level of Evidence: C)
Class IIa
- 1.The use of the LIMA is reasonable to bypass a significantly narrowed LAD artery in patients undergoing noncoronary cardiac surgery. (Level of Evidence: C)
- 2.CABG of moderately diseased coronary arteries (>50% luminal diameter narrowing) is reasonable in patients undergoing noncoronary cardiac surgery. (Level of Evidence: C)
3. CAD Revascularization: Recommendations
Recommendations and text in this section are the result of extensive collaborative discussions between the PCI and CABG writing committees as well as key members of the SIHD and Unstable Angina/Non-ST-Elevation Myocardial Infarction (UA/NSTEMI) writing committees. Certain issues, such as older versus more contemporary studies, primary analyses versus subgroup analyses, and prospective versus post hoc analyses, have been carefully weighed in designating COR and LOE; they are addressed in the appropriate corresponding text.
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- Hillis L.D.
- Smith P.K.
- Anderson J.L.
- 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.
J Am Coll Cardiol. 2011; (published online before print November 7, 2011, doi:10.1016/j.jacc.2011.08.009. Accessed November 7, 2011)
The goals of revascularization for patients with CAD are to (1) to improve survival and (2) to relieve symptoms. The following text contains recommendations for revascularization toimprove survival and symptoms. These recommendations are summarized in Table 2, Table 3.
Table 2Revascularization to improve survival compared with medical therapy
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CABG, Coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not applicable; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between percutaneous coronary intervention with TAXUS and cardiac surgery; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; UPLM, unprotected left main; VT, ventricular tachycardia. ∗In patients with multivessel disease who also have diabetes, it is reasonable to choose CABG (with LIMA) over PCI
155
, 168
, 169
, 170
, 171
, 172
, 173
, 174
, - Niles N.W.
- McGrath P.D.
- Malenka D.
- et al.
Survival of patients with diabetes and multivessel coronary artery disease after surgical or percutaneous coronary revascularization: results of a large regional prospective study.
Northern New England Cardiovascular Disease Study Group. J Am Coll Cardiol. 2001; 37: 1008-1015
175
(Class IIa/LOE: B).Table 3Revascularization to improve symptoms with significant anatomic (≥50% left main or ≥70% non–left main CAD) or physiological (FFR≤0.80) coronary artery stenoses
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CABG, Coronary artery bypass graft; CAD, coronary artery disease; COR, class of recommendation; FFR, fractional flow reserve; GDMT, guideline-directed medical therapy; LOE, level of evidence; N/A, not applicable; PCI, percutaneous coronary intervention; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TMR, transmyocardial laser revascularization.
Revascularization recommendations in this section are predominantly based on studies of patients with symptomatic SIHD and should be interpreted in this context. As discussed later in this section, recommendations on the type of revascularization are, in general, applicable to patients with UA/NSTEMI. In some cases (eg, unprotected left main CAD), specific recommendations are made for patients with UA/NSTEMI or STEMI.
3.1 Heart Team Approach to Revascularization Decisions
Class I
- 1.A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD.105,106,
- King S.B.I.
- Barnhart H.X.
- Kosinski A.S.
- et al.
Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes: Emory Angioplasty versus Surgery Trial Investigators.Am J Cardiol. 1997; 79: 1453-1459107(Level of Evidence: C)
Class IIa
- 1.Calculation of the STS and SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores is reasonable in patients with unprotected left main and complex CAD.107,108,109,110,111,
- Morice M.C.
- Serruys P.W.
- Kappetein A.P.
- et al.
Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.Circulation. 2010; 121: 2645-2653112,113,114(Level of Evidence: B)
3.2 Revascularization to Improve Survival
Left Main CAD Revascularization
Class I
Class IIa
- 1.PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: (1) anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome eg, a low SYNTAX score [≤22], ostial or trunk left main CAD); and (2) clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (eg, STS-predicted risk of operative mortality ≥5%).108,110,111,
- Morice M.C.
- Serruys P.W.
- Kappetein A.P.
- et al.
Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.Circulation. 2010; 121: 2645-2653122,123,124,125,126,- Boudriot E.
- Thiele H.
- Walther T.
- et al.
Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis [published correction appears in J Am Coll Cardiol. 2011;57:1792].J Am Coll Cardiol. 2011; 57: 538-545127,128,129,130,131,132,133,134,135,- Park D.W.
- Seung K.B.
- Kim Y.H.
- et al.
Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry.J Am Coll Cardiol. 2010; 56: 117-124136,137,138,139,140,168(Level of Evidence: B) - 2.PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG.111,
- Morice M.C.
- Serruys P.W.
- Kappetein A.P.
- et al.
Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.Circulation. 2010; 121: 2645-2653127,129,130,131,136,137,139,140,141,142(Level of Evidence: B) - 3.PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than Thrombolysis In Myocardial Infarction grade 3, and PCI can be performed more rapidly and safely than CABG.124,143,144(Level of Evidence: C)
Class IIb
- 1.PCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with: (1) anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (eg, low-intermediate SYNTAX score of <33, bifurcation left main CAD); and (2) clinical characteristics that predict an increased risk of adverse surgical outcomes (eg, moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; STS-predicted risk of operative mortality >2%).108,110,111,
- Morice M.C.
- Serruys P.W.
- Kappetein A.P.
- et al.
Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.Circulation. 2010; 121: 2645-2653122,123,124,125,126,- Boudriot E.
- Thiele H.
- Walther T.
- et al.
Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis [published correction appears in J Am Coll Cardiol. 2011;57:1792].J Am Coll Cardiol. 2011; 57: 538-545127,128,129,130,131,132,133,134,135,- Park D.W.
- Seung K.B.
- Kim Y.H.
- et al.
Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry.J Am Coll Cardiol. 2010; 56: 117-124136,137,138,139,140,145(Level of Evidence: B)
Class III: Harm
- 1.PCI to improve survival should not be performed in stable patients with significant (≥50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG.108,110,111,
- Morice M.C.
- Serruys P.W.
- Kappetein A.P.
- et al.
Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.Circulation. 2010; 121: 2645-2653115,116,117,118,119,120,121,122,123(Level of Evidence: B)
Non-Left Main CAD Revascularization
Class I
- 1.CABG to improve survival is beneficial in patients with significant (≥70% diameter) stenoses in 3 major coronary arteries (with or without involvement of the proximal LAD artery) or in the proximal LAD plus 1 other major coronary artery.117,121,146,147,148,149(Level of Evidence: B)
- 2.CABG or PCI to improve survival is beneficial in survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant (≥70% diameter) stenosis in a major coronary artery. (CABG Level of Evidence: B;99,150,151,152PCI Level of Evidence: C150)
Class IIa
- 1.CABG to improve survival is reasonable in patients with significant (≥70% diameter) stenoses in 2 major coronary arteries with severe or extensive myocardial ischemia (eg, high-risk criteria on stress testing, abnormal intracoronary hemodynamic evaluation, or >20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium.153,154,
- Hachamovitch R.
- Hayes S.W.
- Friedman J.D.
- et al.
Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography.Circulation. 2003; 107: 2900-2907155,156(Level of Evidence: B) - 2.CABG to improve survival is reasonable in patients with mild-moderate LV systolic dysfunction (ejection fraction 35% to 50%) and significant (≥70% diameter stenosis) multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization.121,157,158,159,160,161,162,163(Level of Evidence: B)
- 3.CABG with a LIMA graft to improve survival is reasonable in patients with significant (≥70% diameter) stenosis in the proximal LAD artery and evidence of extensive ischemia.30,31,121,148(Level of Evidence: B)
- 4.It is reasonable to choose CABG over PCI to improve survival in patients with complex 3-vessel CAD (eg, SYNTAX score >22), with or without involvement of the proximal LAD artery, who are good candidates for CABG.123,138,148,164,165(Level of Evidence: B)
- 5.CABG is probably recommended in preference to PCI to improve survival in patients with multivessel CAD and diabetes mellitus, particularly if a LIMA graft can be anastomosed to the LAD artery.155,168,169,170
- Banning A.P.
- Westaby S.
- Morice M.C.
- et al.
Diabetic and nondiabetic patients with left main and/or 3-vessel coronary artery disease: comparison of outcomes with cardiac surgery and paclitaxel-eluting stents.J Am Coll Cardiol. 2010; 55