CABG Guidelines

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CABG Guidelines

  1. 1. CABG GUIDELINES SANJAY DRAVID, M.D.
  2. 2. INTRODUCTION <ul><li>ACC/AHA GUIDELINE UPDATE FOR CORONARY ARTERY BYPASS GRAFT SURGERY (JACC 2004; 44:1146-54 AND CIRCULATION 2004:110:1168-1176) </li></ul><ul><li>WWW.ACC.ORG OR WWW.AMERICANHEART.ORG </li></ul>
  3. 3. INTRO CONT’D <ul><li>CABG IS AMONG THE MOST COMMON OPERATIONS PERFORMED IN THE WORLD AND ACCOUNTS FOR MORE RESOURCES EXPENDED IN CARDIOVASCULAR MEDICINE THAN ANY OTHER SINGLE PROCEDURE </li></ul><ul><li>ORIGINAL GUIDELINES SET IN 1991 </li></ul>
  4. 4. INTRO CONT’D <ul><li>MOST RECENTLY ACC/AHA REVISED GUIDELINES IN 2004 WHICH UPDATED AN INITIAL LANDMARK STANDARD FROM 1999 WHICH INCLUDED COMPUTERIZED SEARCH OF ENGLISH LITERATURE ON CABG, SEVERAL RCT’S, AND EXPERT OPINION. </li></ul><ul><li>LEVEL OF EVIDENCE… </li></ul>
  5. 6. OUTCOMES <ul><li>A. MORTALITY (7 CORE VARIABLES) </li></ul><ul><li>1. Priority of operation </li></ul><ul><li>2. Prior heart surgery </li></ul><ul><li>3. LVEF </li></ul><ul><li>4. # of major arteries w/ significant stenosis </li></ul><ul><li>5. Advanced age </li></ul><ul><li>6. Gender </li></ul><ul><li>7. % stenosis of L Main </li></ul>
  6. 9. OUTCOMES <ul><li>B. MORBIDITY </li></ul><ul><li>1. NEUROLOGICAL EVENTS (6%) </li></ul><ul><li>a. OPCAB? </li></ul><ul><li>2. MEDIASTINITIS (1-4%, 25% death) </li></ul><ul><li>3. RENAL (8%, 18% HD, 19% death, </li></ul><ul><li>67% death in HD) </li></ul><ul><li>a. Cr > 2.5 (40-50% require HD) </li></ul>
  7. 10. MEDICAL VS. SURGICAL <ul><li>META-ANALYSIS OF 7 TRIALS (2,649 TOTAL ENROLLMENT) COMPARING OUTCOMES AT 5 AND 10 YEARS. </li></ul><ul><li>OVERALL, THEY CLAIM ONLY 4.3 MOS. EXTENSION AT 10 YRS. W/ SURGERY </li></ul><ul><li>LEFT MAIN: MEDIAN SURVIVAL 13.3 (SURGERY) VS. 6.6 YRS (MEDICAL). </li></ul><ul><li>3VD: 7 MO. EXTENSION FOR CABG </li></ul><ul><li>MORE BENEFIT FROM CABG FOR SEVERE ANGINA, LV DYSFUNCTION, LAD STENOSIS. </li></ul>
  8. 11. MED VS. SURG CONT’D <ul><li>PROX. LAD: RRR 42% AT 5 YRS. AND 22% AT 10 YRS. </li></ul><ul><li>QUALITY OF LIFE: 63% SX FREE W/ CABG AT 5 YRS. COMPARED TO 38% OF MEDICALLY ASSIGNED PATIENTS </li></ul><ul><li>LONG-TERM (10-12 YR. F/U): CURVES FOR NONFATAL AND SURVIVAL TENDED TO CONVERGE (SKEWED?) </li></ul>
  9. 13. CABG VS. PCI <ul><li>1. CABG VS. PTCA </li></ul><ul><li>-EXCLUDED PATIENTS IN WHOM SURVIVAL BENEFIT ALREADY CONFERRED W/ CABG VS. MEDICAL TX </li></ul><ul><li>-NOT FULLY POWERED TO DETECT MODEST DIFFERENCES IN SURIVIVAL BETWEEN THE TWO APPROACHES </li></ul>
  10. 14. CABG VS. PTCA <ul><li>(BARI) BYPASS ANGIOPLASTY REVASCULARIZATION INVESTIGATION </li></ul><ul><li>1. MEAN 7.8 YEAR F/U </li></ul><ul><li>2. SURVIVAL RATE 84.4% VS. 80.9% (PTCA) P=0.043  MARKED BENEFIT IN DM…76.4% VS. 55.7% (PTCA) P=0.0011 </li></ul><ul><li>3. X4-10 INCREASE IN REINTERVENTION </li></ul>
  11. 15. CABG VS. PTCA <ul><li>4. QUALITY OF LIFE, PHYSICAL ACTIVITY, EMPLOYMENT, AND COST WERE SIMILAR AT 3-5 YEARS </li></ul>
  12. 17. CABG VS. STENT <ul><li>SEVERAL TRIALS COMPARING STENTS W/ CABG IN MULTIVESSEL DZ. HAVE BEEN INITIATED. </li></ul><ul><li>(ARTS) ARTERIAL REVASCULARIZATION THERAPIES STUDY GROUP ENROLLED 1205 PATIENTS  BARE METAL STENTS </li></ul><ul><li>OVERALL EVENT-FREE SURVIVAL WAS SIMILAR </li></ul>
  13. 18. CABG VS. STENT <ul><li>REPEAT VASCULARIZATION WAS HIGHER W/ STENTS ESPECIALLY IN DM PATIENTS </li></ul><ul><li>NET COST SAVINGS $2973 </li></ul><ul><li>F/U OF ONLY 2 YEARS ON AVERAGE </li></ul><ul><li>(SoS) STENT OR SURGERY: ENROLLED 988 PATIENTS W/ MULTIVESSEL DZ (57% 3VD) </li></ul>
  14. 19. CABG VS. STENT <ul><li>PRIMARY END POINT OF REVASCULARIZATION 21% (PCI) VS. 6% (CABG) MEDIAN F/U OF 2 YRS. (HAZARD RATIO = 3.85, P<0.0001) </li></ul><ul><li>(AWESOME) 454 PTS. FROM VA’S, SURVIVAL SIMILAR (79% CABG VS. 80% PCI) AT 36 MOS. </li></ul>
  15. 21. CABG VS. STENT <ul><li>OVERALL, SURVIVAL SHORT TERM IS SIMILAR, BUT LONGER TERM OUTCOMES NEEDED </li></ul><ul><li>REVASCULARIZATION IS THE MAIN DISPARITY BUT QUESTIONABLY NARROWING W/ DES </li></ul>
  16. 22. KEYS TO SUCCESSFUL CABG <ul><li>PRE-OP PERIOD: RISK VS. BENEFIT </li></ul><ul><li>1. ESTABLISH THE INDICATION </li></ul><ul><li>2. ASSESS PERIOPERATIVE RISK </li></ul><ul><li>3. ASSESS LONG-TERM OUTCOME </li></ul>
  17. 23. KEYS CONT’D <ul><li>PERIOP PERIOD: REDUCE RISK </li></ul><ul><li>1. CAROTID SCREENING </li></ul><ul><li>2. ABX </li></ul><ul><li>3. POST-OP ARRHYTHMIAS (B-BLOCKERS VS. AMIO.) </li></ul>
  18. 24. KEYS CONT’D <ul><li>IN-HOSPITAL AND DISCHARGE PERIOD: </li></ul><ul><li>1. ASA, LDL TX, SMOKING CESSATION </li></ul><ul><li>2. REFER FOR CARDIAC REHAB. </li></ul>

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