What are the 2014 ACC/AHA guidelines for coronary artery bypass grafting (CABG) in the treatment of ST-elevation myocardial infarction (STEMI) (MI, heart attack)?

Updated: May 07, 2019
  • Author: A Maziar Zafari, MD, PhD, FACC, FAHA; Chief Editor: Eric H Yang, MD  more...
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Answer

The 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines view coronary artery bypass grafting (CABG) as having a limited role in the acute phase of ST-elevation myocardial infarction (STEMI), but they provide a class I recommendation for CABG in patients whose coronary anatomy is not amenable to percutaneous coronary intervention (PCI) and who have ongoing or recurrent ischemia or cardiogenic shock. [2]

CABG is also recommended (class I) in patients with STEMI at time of operative repair of mechanical defects such as [2] :

  • Ventricular septal defect related to myocardial infarction (MI)
  • Papillary muscle rupture
  • Free wall rupture

Emergency CABG is not recommended in patients with the following conditions [130] :

  • Persistent angina, a small area of viable myocardium, and hemodynamically stable
  • No-reflow state (successful epicardial reperfusion with unsuccessful microvascular reperfusion)

In addition, CABG is not advised for patients with ventricular tachycardia with scar and no evidence of ischemia. [130]

The 2017 European Society of Cardiology guidelines indicate emergent CABG should be considered in patients with a patent infarct-related artery whose anatomy is unsuitable for PCI, and either a large at-risk myocardial area or with cardiogenic shock. [70] The benefits of surgical revascularization are unclear in the setting of emergent CABG in patients who have experienced a failed PCI or have a coronary occlusion not amenable to PCI. CABG is recommended at the time of repair for those with mechanical complications associated with MI who require coronary revascularization. [70]


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