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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.

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CABG GUIDELINES

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  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.

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