CABG Guidelines

CABG GUIDELINESCABG GUIDELINES

SANJAY DRAVID, M.D.SANJAY DRAVID, M.D.

INTRODUCTIONINTRODUCTION

ACC/AHA GUIDELINE UPDATE FOR ACC/AHA GUIDELINE UPDATE FOR CORONARY ARTERY BYPASS GRAFT CORONARY ARTERY BYPASS GRAFT SURGERY (JACC 2004; 44:1146-54 AND SURGERY (JACC 2004; 44:1146-54 AND CIRCULATION 2004:110:1168-1176)CIRCULATION 2004:110:1168-1176)

WWW.ACC.ORGWWW.ACC.ORG OR OR WWW.AMERICANHEART.ORGWWW.AMERICANHEART.ORG

INTRO CONT’DINTRO CONT’D

CABG IS AMONG THE MOST COMMON CABG IS AMONG THE MOST COMMON OPERATIONS PERFORMED IN THE OPERATIONS PERFORMED IN THE WORLD AND ACCOUNTS FOR MORE WORLD AND ACCOUNTS FOR MORE RESOURCES EXPENDED IN RESOURCES EXPENDED IN CARDIOVASCULAR MEDICINE THAN CARDIOVASCULAR MEDICINE THAN ANY OTHER SINGLE PROCEDUREANY OTHER SINGLE PROCEDURE

ORIGINAL GUIDELINES SET IN 1991ORIGINAL GUIDELINES SET IN 1991

INTRO CONT’DINTRO CONT’D

MOST RECENTLY ACC/AHA REVISED MOST RECENTLY ACC/AHA REVISED GUIDELINES IN 2004 WHICH UPDATED GUIDELINES IN 2004 WHICH UPDATED AN INITIAL LANDMARK STANDARD AN INITIAL LANDMARK STANDARD FROM 1999 WHICH INCLUDED FROM 1999 WHICH INCLUDED COMPUTERIZED SEARCH OF ENGLISH COMPUTERIZED SEARCH OF ENGLISH LITERATURE ON CABG, SEVERAL LITERATURE ON CABG, SEVERAL RCT’S, AND EXPERT OPINION.RCT’S, AND EXPERT OPINION.

LEVEL OF EVIDENCE…LEVEL OF EVIDENCE…

OUTCOMESOUTCOMES

A. MORTALITY (7 CORE VARIABLES)A. MORTALITY (7 CORE VARIABLES)

1. Priority of operation1. Priority of operation

2. Prior heart surgery2. Prior heart surgery

3. LVEF3. LVEF

4. # of major arteries w/ significant stenosis4. # of major arteries w/ significant stenosis

5. Advanced age5. Advanced age

6. Gender6. Gender

7. % stenosis of L Main7. % stenosis of L Main

OUTCOMESOUTCOMES

B. MORBIDITYB. 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. SURGICALMEDICAL VS. SURGICAL

META-ANALYSIS OF 7 TRIALS (2,649 TOTAL META-ANALYSIS OF 7 TRIALS (2,649 TOTAL ENROLLMENT) COMPARING OUTCOMES AT ENROLLMENT) COMPARING OUTCOMES AT 5 AND 10 YEARS.5 AND 10 YEARS.OVERALL, THEY CLAIM ONLY 4.3 MOS. OVERALL, THEY CLAIM ONLY 4.3 MOS. EXTENSION AT 10 YRS. W/ SURGERYEXTENSION AT 10 YRS. W/ SURGERYLEFT MAIN: MEDIAN SURVIVAL 13.3 LEFT MAIN: MEDIAN SURVIVAL 13.3 (SURGERY) VS. 6.6 YRS (MEDICAL).(SURGERY) VS. 6.6 YRS (MEDICAL).3VD: 7 MO. EXTENSION FOR CABG3VD: 7 MO. EXTENSION FOR CABG

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

MED VS. SURG CONT’DMED VS. SURG CONT’D

PROX. LAD: RRR 42% AT 5 YRS. AND PROX. LAD: RRR 42% AT 5 YRS. AND 22% AT 10 YRS. 22% AT 10 YRS.

QUALITY OF LIFE: 63% SX FREE W/ QUALITY OF LIFE: 63% SX FREE W/ CABG AT 5 YRS. COMPARED TO 38% CABG AT 5 YRS. COMPARED TO 38% OF MEDICALLY ASSIGNED PATIENTSOF MEDICALLY ASSIGNED PATIENTS

LONG-TERM (10-12 YR. F/U): CURVES LONG-TERM (10-12 YR. F/U): CURVES FOR NONFATAL AND SURVIVAL FOR NONFATAL AND SURVIVAL TENDED TO CONVERGE (SKEWED?) TENDED TO CONVERGE (SKEWED?)

CABG VS. PCICABG VS. PCI

1. CABG VS. PTCA 1. CABG VS. PTCA

-EXCLUDED PATIENTS IN WHOM -EXCLUDED PATIENTS IN WHOM SURVIVAL BENEFIT ALREADY SURVIVAL BENEFIT ALREADY CONFERRED W/ CABG VS. MEDICAL CONFERRED W/ CABG VS. MEDICAL TXTX

-NOT FULLY POWERED TO DETECT -NOT FULLY POWERED TO DETECT MODEST DIFFERENCES IN SURIVIVAL MODEST DIFFERENCES IN SURIVIVAL BETWEEN THE TWO APPROACHESBETWEEN THE TWO APPROACHES

CABG VS. PTCACABG VS. PTCA

(BARI) BYPASS ANGIOPLASTY (BARI) BYPASS ANGIOPLASTY REVASCULARIZATION INVESTIGATIONREVASCULARIZATION INVESTIGATION

1. MEAN 7.8 YEAR F/U1. MEAN 7.8 YEAR F/U

2. SURVIVAL RATE 84.4% VS. 80.9% 2. SURVIVAL RATE 84.4% VS. 80.9% (PTCA) P=0.043(PTCA) P=0.043 MARKED BENEFIT IN MARKED BENEFIT IN DM…76.4% VS. 55.7% (PTCA) P=0.0011DM…76.4% VS. 55.7% (PTCA) P=0.0011

3. X4-10 INCREASE IN 3. X4-10 INCREASE IN REINTERVENTIONREINTERVENTION

CABG VS. PTCACABG VS. PTCA

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

CABG VS. STENTCABG VS. STENT

SEVERAL TRIALS COMPARING SEVERAL TRIALS COMPARING STENTS W/ CABG IN MULTIVESSEL DZ. STENTS W/ CABG IN MULTIVESSEL DZ. HAVE BEEN INITIATED.HAVE BEEN INITIATED.(ARTS) ARTERIAL (ARTS) ARTERIAL REVASCULARIZATION THERAPIES REVASCULARIZATION THERAPIES STUDY GROUP ENROLLED 1205 STUDY GROUP ENROLLED 1205 PATIENTSPATIENTS BARE METAL STENTS BARE METAL STENTSOVERALL EVENT-FREE SURVIVAL OVERALL EVENT-FREE SURVIVAL WAS SIMILAR WAS SIMILAR


REPEAT VASCULARIZATION WAS REPEAT VASCULARIZATION WAS HIGHER W/ STENTS ESPECIALLY IN HIGHER W/ STENTS ESPECIALLY IN DM PATIENTSDM PATIENTS

NET COST SAVINGS $2973NET COST SAVINGS $2973

F/U OF ONLY 2 YEARS ON AVERAGEF/U OF ONLY 2 YEARS ON AVERAGE

(SoS) STENT OR SURGERY: (SoS) STENT OR SURGERY: ENROLLED 988 PATIENTS W/ ENROLLED 988 PATIENTS W/ MULTIVESSEL DZ (57% 3VD) MULTIVESSEL DZ (57% 3VD)


PRIMARY END POINT OF PRIMARY END POINT OF REVASCULARIZATION 21% (PCI) VS. REVASCULARIZATION 21% (PCI) VS. 6% (CABG) MEDIAN F/U OF 2 YRS. 6% (CABG) MEDIAN F/U OF 2 YRS. (HAZARD RATIO = 3.85, P<0.0001)(HAZARD RATIO = 3.85, P<0.0001)

(AWESOME) 454 PTS. FROM VA’S, (AWESOME) 454 PTS. FROM VA’S, SURVIVAL SIMILAR (79% CABG VS. SURVIVAL SIMILAR (79% CABG VS. 80% PCI) AT 36 MOS. 80% PCI) AT 36 MOS.


OVERALL, SURVIVAL SHORT TERM IS OVERALL, SURVIVAL SHORT TERM IS SIMILAR, BUT LONGER TERM SIMILAR, BUT LONGER TERM OUTCOMES NEEDEDOUTCOMES NEEDED

REVASCULARIZATION IS THE MAIN REVASCULARIZATION IS THE MAIN DISPARITY BUT QUESTIONABLY DISPARITY BUT QUESTIONABLY NARROWING W/ DES NARROWING W/ DES

KEYS TO SUCCESSFUL CABGKEYS TO SUCCESSFUL CABG

PRE-OP PERIOD: RISK VS. BENEFITPRE-OP PERIOD: RISK VS. BENEFIT

1. ESTABLISH THE INDICATION1. ESTABLISH THE INDICATION

2. ASSESS PERIOPERATIVE RISK2. ASSESS PERIOPERATIVE RISK

3. ASSESS LONG-TERM OUTCOME3. ASSESS LONG-TERM OUTCOME

KEYS CONT’DKEYS CONT’D

PERIOP PERIOD: REDUCE RISKPERIOP PERIOD: REDUCE RISK

1. CAROTID SCREENING1. CAROTID SCREENING

2. ABX2. ABX

3. POST-OP ARRHYTHMIAS (B-3. POST-OP ARRHYTHMIAS (B-BLOCKERS VS. AMIO.)BLOCKERS VS. AMIO.)

KEYS CONT’D KEYS CONT’D

IN-HOSPITAL AND DISCHARGE IN-HOSPITAL AND DISCHARGE PERIOD:PERIOD:

1. ASA, LDL TX, SMOKING CESSATION1. ASA, LDL TX, SMOKING CESSATION

2. REFER FOR CARDIAC REHAB.2. REFER FOR CARDIAC REHAB.

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CABG Guidelines