II. Efficacy
- Graft patency after Coronary Artery Bypass Graft
- Internal mammary graft stays patent in >90% for >10 years
- Saphenous vein graft patency is much more tenuous
- Year 2: 85% are patent
- Year 5: 75% are patent
- Year 8: 65% are patent
- References
III. Precautions: PTCA as an alternative for Left Main Disease
-
PTCA with DES may be a reasonable alternative to CABG in moderate coronary disease cases previously limited to CABG (e.g. Left main disease)
- For moderate left main disease, PTCA with DES outcomes over 10 years are similar to CABG outcomes
- PTCA is a safe, much less invasive procedure than CABG
- CABG has a higher rate of perioperative Cerebrovascular Accident
- Caveats
- CABG is associated with decreased Angina
- CABG is associated with a better outcome with severe left main disease or multi-vessel disease
- CABG has better outcomes when repeat revascularization is required
- References
- Rihal (2012) Mayo POIM Conference, Rochester
IV. Indications: Absolute Indications in Stable CAD
- Disabling Angina despite maximal medical therapy given acceptable surgical risk
- If atypical Angina, confirm cardiac ischemia is cause of symptoms
- Significant proximal LAD stenosis (>70%)
- Significant left main Coronary Artery stenosis
- One to two vessel CAD (without proximal LAD stenosis)
- LARGE area of viable Myocardium and
- High risk criteria on noninvasive testing
- Two vessel CAD
- Significant proximal LAD stenosis and
- Ejection Fraction (EF) <50% or ischemia on noninvasive testing
- Three vessel CAD
- Especially if Ejection Fraction (EF) <50%
V. Indications: Possible Indications in Stable CAD
- One vessel CAD and
- Proximal LAD Stenosis
- One to two vessel CAD (without proximal LAD stenosis)
- MODERATE area of viable Myocardium and
- Ischemia on noninvasive testing
VI. Indications: Avoid CABG in these patients (cases in which CABG is NOT recommended)
- Borderline Coronary Artery stenosis (<60%) not involving left main Coronary Artery and negative noninvasive testing
- Insignificant Coronary Artery stenosis (<50%)
- One to two vessel CAD (without proximal LAD stenosis)
- SMALL area of viable Myocardium and
- No ischemia on noninvasive testing and
- Mild symptoms unlikely to be ischemia or inadequate medical management trial
VII. Complications (based on STS Guidelines from 2008)
- Transfusion required: <50%
- Incomplete revascularization: <20%
- Major morbidity (e.g. CVA): <5%
- Mortality: <2%
VIII. Management: Perioperative Medications and Interventions to reduce readmission rates
-
General
- Collaborate with managing cardiology team
- Adjust medications based on Renal Function, compliance, cost
-
Aspirin
- Dose: 325 mg orally daily for one year, then 81 mg daily
- Start and continue 81 mg daily if comorbid bleeding risks
- Consider dual antiplatelet agents (Aspirin with Clopidogrel) for 1 year following MI (if low bleeding risk)
-
Beta Blockers
- Start at least several days prior to CABG to reduce Atrial Fibrillation risk
- Titrate Heart Rate to 60 bpm as tolerated
- Heart Failure with Reduced Ejection Fraction (HFrEF) preferred agents (best evidence)
- Atrial Fibrillation WITHOUT HFrEF
- Any cardioselective Beta Blocker (e.g. Metoprolol, Bisoprolol, Nebivolol)
- Duration
- Continue for 1 month following CABG at a minimum
- Continue for at least 3 years following Myocardial Infarction
- Continue indefinately for Systolic Dysfunction
- Start at least several days prior to CABG to reduce Atrial Fibrillation risk
-
Statins
- High dose Statin (e.g. Atorvastatin 80 mg, Rosuvastatin 20-40 mg) for most patients
- Low dose Statin for those who cannot tolerate high dose
- Target LDL Cholesterol decrease of >50% AND LDL Cholesterol <55 mg/dl
- Consider adding Ezetimibe (Zetia)
- Consider adding PCSK9 Inhibitor
- Consider adding Bempedoic Acid
- High dose Statin (e.g. Atorvastatin 80 mg, Rosuvastatin 20-40 mg) for most patients
-
ACE Inhibitors, Angiotensin Receptor Blockers
- Symptomatic Heart Failure with reduced EF (HFrEF) with or without prior Myocardial Infarction (MI)
- Sacubitril/Valsartan (preferred) OR
- ACE Inhibitor OR
- Angiotensin Receptor Blocker (ARB)
- Asymptomatic HFrEF (or Hypertension, Diabetes Mellitus) with goal BP <130/80
- Symptomatic Heart Failure with reduced EF (HFrEF) with or without prior Myocardial Infarction (MI)
- Mineralcorticoid Antagonist
- Indications
- NYHA Class 2 to 4 Heart Failure with Ejection Fraction (EF) <35%
- Contraindications
- eGFR <30 ml/min/1.73 m2
- Serum Potassium >5 mEq/L
- Medications
- Spironolactone or Eplerenone (preferred)
- Finerenone (not routinely recommended, not studied in EF<40% and post-CABG)
- Indications
-
Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine)
- Consider for up to 1 year following CABG to reduce risk of vasospasm (esp. if radial artery graft used)
-
SGLT2 Inhibitor (e.g. Empagliflozin) Indications
- Heart Failure (regardless of EF)
- Type 2 Diabetes Mellitus (regardless of Hemoglobin A1C)
-
GLP1 Agonist (e.g. Semaglutide) Indications
- Type 2 Diabetes Mellitus (regardless of Hemoglobin A1C)
- Body Mass Index >27 kg/m2 (without Diabetes Mellitus)
-
Cardiac Rehabilitation
- Reduces risk of future Myocardial Infarctions
- Reduces readmission rates and mortality rates
- Reinforces Medication Compliance
- Follow-up
- Phone follow-up within 2-3 days of CABG discharge
- Office follow-up within 7-14 days of CABG discharge
- References