CABG GUIDELINES

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CABG GUIDELINES

• SANJAY DRAVID, M.D.

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INTRODUCTION

• ACC/AHA GUIDELINE UPDATE FOR CORONARY ARTERY
  BYPASS GRAFT SURGERY (JACC 2004 441146-54 AND
  CIRCULATION 20041101168-1176)
• WWW.ACC.ORG OR WWW.AMERICANHEART.ORG

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INTRO CONTD

• CABG IS AMONG THE MOST COMMON OPERATIONS
  PERFORMED IN THE WORLD AND ACCOUNTS FOR MORE
  RESOURCES EXPENDED IN CARDIOVASCULAR MEDICINE
  THAN ANY OTHER SINGLE PROCEDURE
• ORIGINAL GUIDELINES SET IN 1991

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INTRO CONTD

• MOST RECENTLY ACC/AHA REVISED GUIDELINES IN 2004
  WHICH UPDATED AN INITIAL LANDMARK STANDARD FROM
  1999 WHICH INCLUDED COMPUTERIZED SEARCH OF
  ENGLISH LITERATURE ON CABG, SEVERAL RCTS, AND
  EXPERT OPINION.
• LEVEL OF EVIDENCE

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OUTCOMES

• A. MORTALITY (7 CORE VARIABLES)
• 1. Priority of operation
• 2. Prior heart surgery
• 3. LVEF
• 4. of major arteries w/ significant stenosis
• 5. Advanced age
• 6. Gender
• 7. stenosis of L Main

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OUTCOMES

• B. MORBIDITY
• 1. NEUROLOGICAL EVENTS (6)
• a. OPCAB?
• 2. MEDIASTINITIS (1-4, 25 death)
• 3. RENAL (8, 18 HD, 19 death,
• 67 death in HD)
• a. Cr gt 2.5 (40-50 require HD)

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MEDICAL VS. SURGICAL

• META-ANALYSIS OF 7 TRIALS (2,649 TOTAL
  ENROLLMENT) COMPARING OUTCOMES AT 5 AND 10 YEARS.
• OVERALL, THEY CLAIM ONLY 4.3 MOS. EXTENSION AT 10
  YRS. W/ SURGERY
• LEFT MAIN MEDIAN SURVIVAL 13.3 (SURGERY) VS. 6.6
  YRS (MEDICAL).
• 3VD 7 MO. EXTENSION FOR CABG
• MORE BENEFIT FROM CABG FOR SEVERE ANGINA, LV
  DYSFUNCTION, LAD STENOSIS.

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MED VS. SURG CONTD

• PROX. LAD RRR 42 AT 5 YRS. AND 22 AT 10 YRS.
• QUALITY OF LIFE 63 SX FREE W/ CABG AT 5 YRS.
  COMPARED TO 38 OF MEDICALLY ASSIGNED PATIENTS
• LONG-TERM (10-12 YR. F/U) CURVES FOR NONFATAL
  AND SURVIVAL TENDED TO CONVERGE (SKEWED?)

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CABG VS. PCI

• 1. CABG VS. PTCA
• -EXCLUDED PATIENTS IN WHOM SURVIVAL BENEFIT
  ALREADY CONFERRED W/ CABG VS. MEDICAL TX
• -NOT FULLY POWERED TO DETECT MODEST DIFFERENCES
  IN SURIVIVAL BETWEEN THE TWO APPROACHES

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CABG VS. PTCA

• (BARI) BYPASS ANGIOPLASTY REVASCULARIZATION
  INVESTIGATION
• 1. MEAN 7.8 YEAR F/U
• 2. SURVIVAL RATE 84.4 VS. 80.9 (PTCA) P0.043?
  MARKED BENEFIT IN DM76.4 VS. 55.7 (PTCA)
  P0.0011
• 3. X4-10 INCREASE IN REINTERVENTION

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CABG VS. PTCA

• 4. QUALITY OF LIFE, PHYSICAL ACTIVITY,
  EMPLOYMENT, AND COST WERE SIMILAR AT 3-5 YEARS

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CABG VS. STENT

• SEVERAL TRIALS COMPARING STENTS W/ CABG IN
  MULTIVESSEL DZ. HAVE BEEN INITIATED.
• (ARTS) ARTERIAL REVASCULARIZATION THERAPIES STUDY
  GROUP ENROLLED 1205 PATIENTS? BARE METAL STENTS
• OVERALL EVENT-FREE SURVIVAL WAS SIMILAR

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CABG VS. STENT

• REPEAT VASCULARIZATION WAS HIGHER W/ STENTS
  ESPECIALLY IN DM PATIENTS
• NET COST SAVINGS 2973
• F/U OF ONLY 2 YEARS ON AVERAGE
• (SoS) STENT OR SURGERY ENROLLED 988 PATIENTS W/
  MULTIVESSEL DZ (57 3VD)

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CABG VS. STENT

• PRIMARY END POINT OF REVASCULARIZATION 21 (PCI)
  VS. 6 (CABG) MEDIAN F/U OF 2 YRS. (HAZARD RATIO
  3.85, Plt0.0001)
• (AWESOME) 454 PTS. FROM VAS, SURVIVAL SIMILAR
  (79 CABG VS. 80 PCI) AT 36 MOS.

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CABG VS. STENT

• OVERALL, SURVIVAL SHORT TERM IS SIMILAR, BUT
  LONGER TERM OUTCOMES NEEDED
• REVASCULARIZATION IS THE MAIN DISPARITY BUT
  QUESTIONABLY NARROWING W/ DES

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KEYS TO SUCCESSFUL CABG

• PRE-OP PERIOD RISK VS. BENEFIT
• 1. ESTABLISH THE INDICATION
• 2. ASSESS PERIOPERATIVE RISK
• 3. ASSESS LONG-TERM OUTCOME

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KEYS CONTD

• PERIOP PERIOD REDUCE RISK
• 1. CAROTID SCREENING
• 2. ABX
• 3. POST-OP ARRHYTHMIAS (B-BLOCKERS VS. AMIO.)

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KEYS CONTD

• IN-HOSPITAL AND DISCHARGE PERIOD
• 1. ASA, LDL TX, SMOKING CESSATION
• 2. REFER FOR CARDIAC REHAB.