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Contact: cfeheley@acc.org;
800-253-4636; 301-581-3425
August 5, 2004
CABG
Guidelines Get New Update
Hormone replacement out, aspirin in, as cardiology experts
change the rules for coronary artery bypass graft surgery.
(BETHESDA, MD)—The American College of Cardiology (ACC)
and the American Heart Association (AHA) have issued a revised
set of guidelines for the management of patients undergoing
coronary artery bypass grafting. In contrast to the previous
guidelines published in 1999, the new update says no to hormone
replacement therapy and yes to aspirin for patients undergoing
this common surgical procedure.
The
new guidelines also stress the importance of statin and beta
blocker therapy in all post-CABG patients, as well as anticoagulation
with warfarin in patients who develop sustained abnormal heart
rhythms after bypass. The document is published on the Web
sites of the American College of Cardiology at http://www.acc.org/clinical/guidelines/cabg/index.pdf
and the American Heart Association www.americanheart.org
and will appear in the September 1 issue of the Journal
of the American College of Cardiology and the August
31 issue of the Circulation: Journal of the American Heart
Association.
“We’ve
significantly updated a number of sections of the 1999 guidelines
to incorporate the most recent evidence from randomized trials.
One important example is in the area of hormone replacement.
Until the randomized trials were published, we were generally
recommending the initiation of hormone therapy in women after
their bypass, but in this document, it is not recommended
at all,” said Dr. Kim Eagle, co-chair of the guidelines
writing committee.
The
updated guidelines continue to emphasize quality of life as
well as quantity. “The guidelines now recognize that
CABG is very effective for the relief of symptoms, even when
it may not prolong life,” said Dr. Robert A. Guyton,
co-chair of the writing committee. “This is an important
evolution for us. In the 1990s, when guidelines for CABG were
first issued, we focused more on quantity, but now we are
interested in the quality of life, as well as length of life,”
he said.
An
important aim of the revised guidelines is to optimize the
medical management of bypass surgery patients, Dr. Eagle said.
“They really focus on treating atherosclerosis after
CABG. For example, in the past, many patients were told to
discontinue aspirin for some time prior to their surgery to
reduce bleeding risk, but now we know that staying on aspirin
is good for patients because it reduces the likelihood that
their grafts will clot,” he said.
Another
area that has been significantly updated is the section comparing
multivessel angioplasty and stenting with bypass surgery.
Recent evidence from randomized trials now suggests that either
option is reasonable, with five-year outcomes of both techniques
showing similar results.
“It’s
fair to say that the era of coronary stenting has improved,
or reduced the need for repeat vascularization in patients
who need stents. At the same time, the broader use of the
left internal mammary artery has improved the benefit of coronary
bypass surgery. So, on the one hand, angioplasty has a lower
upfront risk, but on the other hand, there is a larger likelihood
that patients who get angioplasty will require subsequent
interventions. So, for patients who are eligible for both
therapies, a lot of the final decision comes down to their
own personal preference,” he said.
However,
the jury is still out as to the relative benefit of off-pump
CABG. Although the results of several small studies appear
to show fewer neurologic complications with off-pump bypass,
the guidelines committee did not feel that their evidence
was compelling enough to make a specific recommendation in
favor of the newer technique.
“One
of the big questions many patients have had is whether the
risk of stroke or other neurologic complications is lower
with off-pump bypass surgery. But so far, the answer to that
question is not absolutely clear. If you actually look at
randomized clinical trials that have taken eligible patients
for either methodology, the amount of difference in length
of stay or neurologic complications has not been dramatic
and we still have yet to prove to ourselves that off-pump
bypass is dramatically better than on-pump bypass. We’re
certainly in no position right now to say that every patient
who has bypass surgery should have it off-pump,” Dr.
Eagle said.
The
American College of Cardiology, a 31,000-member nonprofit
professional medical society and teaching institution, is
dedicated to fostering optimal cardiovascular care and disease
prevention through professional education, promotion of research,
leadership in the development of standards and guidelines,
and the formulation of health care policy.
The
American College of Cardiology (ACC) provides these new reports
of clinical studies published in the Journal of the American
College of Cardiology as a service to physicians, the media,
the public, and other interested parties. However, statements
or opinions expressed in these reports reflect the view of
the author(s) and do not represent official policy of the
ACC unless stated so. |
