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The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) today released a rewritten set of guidelines for the management of patients undergoing coronary artery bypass graft surgery (CABG). The 2011 guideline contains the most extensive examination of using CABG or percutaneous coronary intervention (PCI) for coronary revascularization, with the writing committee working collaboratively with members of the PCI guideline writing committee.
The 2011 guideline represents the first time that two writing committees have worked together to author a common section. The coronary artery disease (CAD) revascularization section—which discusses who should be revascularized and whether it should be accomplished with CABG or PCI—is included in revisions to both the 2011 CABG guideline and the 2011 PCI guideline, which were also released by the ACC, AHA and the Society for Cardiovascular Angiography and Interventions (SCAI) today.
L. David Hillis, MD, chair of the CABG guideline writing committee, noted that the updated revascularization section will be of great interest to practicing clinicians. “The question of whom to revascularize and how to do it comes up frequently in a busy practitioner’s office,” he said. “Thus, I think physicians will hone in on this section, because it addresses an everyday question, and because the debate over PCI versus CABG has seen the most action since the 2004 guideline was written.”
According to Hillis, this decision recently has become more complicated, as PCI is now being used in more cases. “What has happened over the last decade is that as PCI has become better; it is now being used for things that it wasn’t being used for 10-15 years ago,” he said. “Just like the development of any new technology, as the PCI technology matured, the procedure has become better, and as the operators have gained more experience, they have also become more skilled.”
Hillis cites the example of left main CAD to illustrate the growing use of PCI. A decade ago, the standard of care for these patients was to receive CABG. Now, however, depending on the specifics of their coronary arterial anatomy, some patients can receive PCI. Specifically, the 2011 guideline states that PCI to improve patient survival is a reasonable alternative to CABG in stable patients with left main CAD who have a low risk of PCI complications and an increased risk of adverse surgical outcomes. The guideline also confirms the superiority of CABG compared to medical therapy and to PCI for most patients with 3-vessel disease.
The guideline further recommends using a “heart team” approach to determine which procedure should be used. This approach means that the interventional cardiologist and the cardiac surgeon will 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.
“It has become apparent that the best recommendations come from the surgeon and cardiologist working together,” said Peter K. Smith, MD, vice chair of the CABG guideline writing committee. “The evidence that we used in writing this recommendation is based on trials where patients were randomized by this sort of a team, and it follows that this is the way we should practice.”
These trials include SYNTAX, which informed decisions on many of the recommendations included in the 2011 guideline. This randomized, controlled trial—which was published in the New England Journal of Medicine in 2009—compared CABG versus PCI in 1,800 patients. It showed that PCI led to outcomes that were comparable to those of CABG for patients with certain coronary arterial anatomic features. Overall, the revised guideline was based on a formal literature review of studies published in the past 10 years.
In addition to the discussion of CABG versus PCI, the 2011 guideline addresses 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 mellitus. One of the most significant issues, notes Hillis, is the examination of preoperative and postoperative antiplatelet therapy.
“Since the last guideline was released, our ability to inhibit platelet aggregation has become much better, since there are now more drugs available,” he said. “It’s no longer just a choice of ‘do they or do they not receive aspirin.’ It is now ‘do they receive aspirin, clopidogrel, a glycoprotein IIb/IIIa inhibitor, or another drug.”
Specifically, the 2011 guideline notes 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 5 days before elective surgery (or at least 24 hours, if possible, for patients needing urgent CABG). Postoperatively, aspirin should be given within 6 hours of surgery (if it wasn’t initiated preoperatively) and then continued indefinitely. Clopidogrel is a “reasonable alternative” in patients who are allergic to aspirin.
While the 2011 guideline includes for the first time a collaborative section on CABG versus PCI, they also mark another first—the implementation of a new policy for relationships with industry and other entities. The new policy requires that the writing committee chair and more than 50 percent of the committee members have no relevant industry relationships.
The revised guideline will be published in the December 6, 2011, issue the Journal of the American College of Cardiology and available before print on Monday, November 7, 2011, at 2 pm ET at http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.08.009. They will also be co-published in the December 6, 2011, issue of Circulation: Journal of the American Heart Association and available before print at on Monday, November 7, 2011, at 2 pm ET at http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0b013e31823c074e.
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The American College of Cardiology is transforming cardiovascular care and improving heart health through continuous quality improvement, patient-centered care, payment innovation and professionalism. The College is a 39,000-member nonprofit medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers and bestows credentials among cardiovascular specialists who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at http://cardiosource.org/ACC.
The American Heart Association is the nation’s oldest and largest voluntary health organization dedicated to fighting heart disease and stroke. Our mission is to build healthier lives by preventing, treating and defeating these diseases. We fund cutting-edge research, conduct lifesaving public and professional educational programs, and advocate to protect public health. To learn more or join us in helping all Americans, call 1-800-AHA-USA1 or visit www.heart.org.