When is coronary artery bypass grafting (CABG) recommended in patients with comorbidities?

Updated: Dec 04, 2019
  • Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Table 2 below shows the recommendations for treatment of patients with acute heart failure in the setting of AMI.

Table 2. Treatment Recommendations for Patients with Acute Heart Failure in Setting of Acute Myocardial Infarction (Open Table in a new window)

 

Class of Recommendation

Level of Evidence

Patients with NSTE-ACS or STEMI and unstable hemodynamics should immediately be transferred for invasive evaluation and target vessel revascularization

Class I

A

Immediate reperfusion is indicated in acute heart failure with ongoing ischemia

Class I

B

Echocardiography should be performed to assess LV function and to exclude mechanical complications

Class I

C

Emergency angiography and revascularization of all critically narrowed arteries by PCI/CABG as appropriate is indicated in patients in cardiogenic shock

Class I

B

IABP insertion is recommended in patients with hemodynamic instability (particularly those in cardiogenic shock and with mechanical complications)

Class I

C

Surgery for mechanical complications of AMI should be performed as soon as possible with persistent hemodynamic deterioration despite IABP

Class I

B

Emergency surgery after failure of PCI or fibrinolysis is indicated only in patients with persistent hemodynamic instability or life-threatening ventricular arrhythmia due to extensive ischemia (left main or severe 3-vessel disease)

Class I

C

If the patient continues to deteriorate without adequate cardiac output to prevent end-organ failure, temporary mechanical assistance (surgical implantation of LVAD/BiVAD) should be considered

Class IIa

C

Routine use of percutaneous centrifugal pumps is not recommended

Class III

B

AMI = acute myocardial infarction; BiVAD = biventricular assist device; CABG = coronary artery bypass grafting; IABP = intra-aortic balloon pump; LV = left ventricle; LVAD = left ventricular assist device; NSTE-ACS = non–ST-segment elevation acute coronary syndrome; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.

Special recommendations in patients with comorbidities are presented in the tables below.

Table 3. Specific Treatment Recommendations for Coronary Artery Disease in Patients with Mild to Moderate Chronic Kidney Disease (Open Table in a new window)

 

Recommendation

Level of Evidence

CABG should be considered, rather than PCI, when the extent of CAD justifies a surgical approach, the patient’s risk profile is acceptable, and the life expectancy is reasonable

Class IIa

B

Off-pump CABG may be considered rather than on-pump CABG

Class IIb

B

For PCI, disease-eluting stents may be considered, rather than bare metal stents

Class IIb

C

CABG = coronary artery bypass grafting; CAD = coronary artery disease; PCI = percutaneous coronary intervention.

  Table 4. Specific Treatment Recommendations for Coronary Artery Disease in Diabetic Patients (Open Table in a new window)

 

Recommendation

Level of Evidence

In patients presenting with STEMI, primary PCI is preferred over fibrinolysis if it can be performed within recommended time limits

Class I

A

In stable patients with extensive CAD, revascularization is indicated to improve MACCE-free survival

Class I

A

Use of drug-eluting stents is recommended to reduce restenosis and repeat target vessel revascularization

Class I

A

In patients on metformin, renal function should be carefully monitored after coronary angiography/PCI

Class I

C

CABG should be considered, rather than PCI, when the extent of CAD justifies a surgical approach (especially multivessel disease) and the patient’s risk profile is acceptable

Class IIa

B

In patients with known renal failure undergoing PCI, metformin may be stopped 48 hours before the procedure

Class IIb

C

Systematic use of glucose insulin potassium in diabetic patients undergoing revascularization is not indicated

Class III

B

CABG = coronary artery bypass grafting; CAD = coronary artery disease; MACCE = major adverse cardiac and cerebral event; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.

  Table 5. Recommendations for Combining Valve Surgery and Coronary Artery Bypass Grafting (Open Table in a new window)

 

Recommendation

Level of Evidence

In combination with valve surgery:

CABG is recommended in patients with a primary indication for aortic/mitral valve surgery and coronary artery stenosis = 70%

Class I

C

CABG should be considered in patients with a primary indication for aortic/mitral valve surgery and coronary artery stenosis of 50-70%

Class IIa

C

In combination with CABG:

Mitral valve surgery is indicated in patients with a primary indication for CABG and severe ischemic mitral regurgitation and an EF >30%*

Class I

C

Mitral valve surgery should be considered in patients with a primary indication for CABG and moderate ischemic mitral regurgitation, provided that valve repair is feasible and performed by experienced operators

Class IIa

C

Aortic valve surgery should be considered in patients with a primary indication for CABG and moderate aortic stenosis (mean gradient 30-50 mm Hg, Doppler velocity of 3-4 m/sec, or heavily calcified aortic valve even with Doppler velocity of 2.5-3 m/sec)

Class IIa

C

* Definition of severe mitral regurgitation is at http://www.escardio.org/guidelines.

CABG = coronary artery bypass grafting; EF = ejection fraction.

  Table 6. Carotid Revascularization in Patients Scheduled for Coronary Artery Bypass Grafting (Open Table in a new window)

 

Recommendation

Level of Evidence

CEA or CAS should be performed only by teams with demonstrated 30-day combined death-stroke rates of < 3% in patients without previous neurologic symptoms and < 6% in patients with previous neurologic symptoms

Class I

A

Indication for carotid revascularization should be individualized after discussion by a multidisciplinary team, including a neurologist

Class I

C

Timing of procedures (synchronous or staged) should be dictated by local expertise and clinical presentation, with the most symptomatic territory targeted first

Class I

C

In patients with previous TIA/nondisabling stroke:

Carotid revascularization is recommended for 70-99% carotid stenosis

Class I

C

Carotid revascularization may be considered for 50-69% carotid stenosis in men with symptoms of < 6 months

Class IIb

C

Carotid revascularization is not recommended if carotid stenosis is < 50% in men and < 70% in women

Class III

C

In patients with no previous TIA/stroke:

Carotid revascularization may be considered in men with bilateral 70-99% carotid stenosis or 70-99% carotid stenosis and contralateral occlusion

Class IIb

C

Carotid revascularization is not recommended in women or patients with a life expectancy < 5 years

Class III

C

CAS = carotid artery stenting; CEA = carotid endarterectomy; TIA = transient ischemic attack.

  Table 7. Management of Patients with Associated Coronary and Peripheral Arterial Disease (Open Table in a new window)

 

Recommendation

Level of Evidence

In patients with unstable CAD, vascular surgery is postponed and CAD treated first, except when vascular surgery cannot be delayed because of a life-threatening condition

Class I

B

Beta-blockers and statins are indicated preoperatively and should be continued postoperatively in patients with known CAD who are scheduled for high-risk vascular surgery

Class I

B

The choice between CABG and PCI should be individualized and assessed by the heart team taking into account the patterns of CAD, PAD, comorbidity, and clinical presentation

Class I

C

Prophylactic myocardial revascularization before high-risk vascular surgery may be considered in stable patients if they have persistent signs of extensive ischemic or high cardiac risk

Class IIb

B

CABG = coronary artery bypass grafting; CAD = coronary artery disease; PAD = peripheral arterial disease; PCI = percutaneous coronary intervention.

  Table 8. Management of Patients with Renal Artery Stenosis (Open Table in a new window)

 

Recommendation

Level of Evidence

Functional assessment of renal artery stenosis severity using pressure gradient measurements may be useful in selecting hypertensive patients who may benefit from renal artery stenting

Class IIb

B

Routine renal artery stenting to prevent deterioration of renal function is not recommended

Class III

B

  Table 9. Recommendations for Patients with Chronic Heart Failure and Systolic Left Ventricular Dysfunction (Ejection Fraction = 35%), Presenting Predominantly with Angina Symptoms (Open Table in a new window)

 

Recommendation

Level of Evidence

CABG is recommended for the following:

  • Significant left main stenosis

  • Left main equivalent (proximal stenosis of both left anterior descending and left circumflex)

  • Proximal left anterior descending stenosis with 2- or 3-vessel disease

Class I

B

CABG with surgical ventricular reconstruction may be considered in patients with LVESV index = 60 mL/m2 and scarred left anterior descending territory

Class IIb

B

PCI may be considered in the presence of viable myocardium if the anatomy is suitable

Class IIb

C

CABG = coronary artery bypass grafting; LVESV = left ventricular end-systolic volume; PCI = percutaneous coronary intervention.

  Table 10. Recommendations for Patients with Chronic Heart Failure and Systolic Left Ventricular Dysfunction (Ejection Fraction = 35%), Presenting Predominantly with Heart Failure Symptoms (No or Mild Angina: Canadian Cardiovascular Society 1-2) (Open Table in a new window)

 

Recommendation

Level of Evidence

LV aneurysmectomy during CABG is indicated in patients with a large LV aneurysm

Class I

C

CABG should be considered in the presence of viable myocardium, irrespective of the LVESV

Class IIa

B

CABG with SVR may be considered in patients with scarred LAD territory

Class IIb

B

PCI may be considered in the presence of viable myocardium if the anatomy is suitable

Class IIb

C

Revascularization in the absence of evidence of myocardial viability is not recommended

Class III

B

CABG = coronary artery bypass grafting; LAD = left anterior descending (artery); LV = left ventricle; LVESV = left ventricular end-systolic volume; PCI = percutaneous coronary intervention; SVR = surgical ventricular reconstruction.


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