Revised CABG guidelines update who to revascularize, how to do it

New guidelines for the management of patients undergoing coronary artery bypass graft surgery (CABG) address patient selection, the role of CABG versus percutaneous coronary interventions (PCI), and the use of aspirin and other platelet therapies before and after surgery.

The guideline writers, representing the American College of Cardiology Foundation and the American Heart Association, noted that use of PCI has expanded and physicians have become more skilled at it, driving changes in the recommendations. The 2011 guidelines state that PCI is a reasonable alternative to CABG in stable patients with left main coronary artery disease who have a low risk of PCI complications and an increased risk of adverse surgical outcomes. The guidelines also confirm the superiority of CABG compared to medical therapy and to PCI for most patients with three-vessel disease.

Preoperative and postoperative antiplatelet therapy were reexamined because the ability to inhibit platelet aggregation has improved, as more drugs have become available since the last set of guidelines was developed. Specifically, the 2011 guidelines note that aspirin should be administered to CABG patients preoperatively, and that in patients receiving elective CABG, clopidogrel and ticagrelor should be discontinued for at least five days before elective surgery (or at least 24 hours, if possible, for patients needing urgent CABG). Postoperatively, aspirin should be given within six hours of surgery (if it was not initiated preoperatively) and then continued indefinitely. Clopidogrel is a “reasonable alternative” in patients who are allergic to aspirin.

The new guidelines address numerous other issues, such as the appropriate choice of bypass graft conduit; the use of off-pump CABG versus traditional on-pump CABG; and CABG in specific patient subsets, such as those with diabetes.

The guidelines, like the revised PCI guidelines, stress the importance of a “heart team” approach in which the interventional cardiologist and the cardiac surgeon review the patient's condition, determine the pros and cons of each treatment option, and then present this information to the patient, allowing him or her to make a more informed decision.

The revised guidelines were based on a formal literature review of studies published in the past 10 years. The societies released the guidelines online on Nov. 7, and they will appear in the Dec. 6 issues of the Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association.