1 / 24

CABG GUIDELINES

CABG GUIDELINES. SANJAY DRAVID, M.D. INTRODUCTION. ACC/AHA GUIDELINE UPDATE FOR CORONARY ARTERY BYPASS GRAFT SURGERY (JACC 2004; 44:1146-54 AND CIRCULATION 2004:110:1168-1176) WWW.ACC.ORG OR WWW.AMERICANHEART.ORG. INTRO CONT’D.

osbourne
Download Presentation

CABG GUIDELINES

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. CABG GUIDELINES SANJAY DRAVID, M.D.

  2. INTRODUCTION • ACC/AHA GUIDELINE UPDATE FOR CORONARY ARTERY BYPASS GRAFT SURGERY (JACC 2004; 44:1146-54 AND CIRCULATION 2004:110:1168-1176) • WWW.ACC.ORG OR WWW.AMERICANHEART.ORG

  3. 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

  4. 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…

  5. 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

  6. 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 > 2.5 (40-50% require HD)

  7. 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.

  8. 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?)

  9. 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

  10. 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=0.0011 • 3. X4-10 INCREASE IN REINTERVENTION

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

  12. 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

  13. 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)

  14. 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.

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

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

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

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

More Related