CABG GUIDELINES SANJAY DRAVID, M.D.

INTRODUCTION ACC/AHA GUIDELINE UPDATE FOR CORONARY ARTERY BYPASS GRAFT SURGERY (JACC 2004; 44: AND CIRCULATION 2004:110: ) OR

INTRO CONT’D 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

INTRO CONT’D 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 RCT’S, AND EXPERT OPINION. LEVEL OF EVIDENCE…

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

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

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. MORE BENEFIT FROM CABG FOR SEVERE ANGINA, LV DYSFUNCTION, LAD STENOSIS.

MED VS. SURG CONT’D 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?)

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

CABG VS. PTCA (BARI) BYPASS ANGIOPLASTY REVASCULARIZATION INVESTIGATION 1. MEAN 7.8 YEAR F/U 2. SURVIVAL RATE 84.4% VS. 80.9% (PTCA) P=0.043  MARKED BENEFIT IN DM…76.4% VS. 55.7% (PTCA) P= X4-10 INCREASE IN REINTERVENTION

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

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

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)

CABG VS. STENT PRIMARY END POINT OF REVASCULARIZATION 21% (PCI) VS. 6% (CABG) MEDIAN F/U OF 2 YRS. (HAZARD RATIO = 3.85, P<0.0001) (AWESOME) 454 PTS. FROM VA’S, SURVIVAL SIMILAR (79% CABG VS. 80% PCI) AT 36 MOS.

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

KEYS TO SUCCESSFUL CABG PRE-OP PERIOD: RISK VS. BENEFIT 1. ESTABLISH THE INDICATION 2. ASSESS PERIOPERATIVE RISK 3. ASSESS LONG-TERM OUTCOME

KEYS CONT’D PERIOP PERIOD: REDUCE RISK 1. CAROTID SCREENING 2. ABX 3. POST-OP ARRHYTHMIAS (B- BLOCKERS VS. AMIO.)

KEYS CONT’D IN-HOSPITAL AND DISCHARGE PERIOD: 1. ASA, LDL TX, SMOKING CESSATION 2. REFER FOR CARDIAC REHAB.