The document discusses guidelines from the ACC/AHA on indications for coronary artery bypass graft (CABG) surgery. It classifies indications into three classes based on evidence: Class I are conditions where CABG is useful and effective, Class II where evidence is conflicting, and Class III where CABG is not useful or effective. It provides the classification for various coronary artery disease presentations such as left main stenosis, multi-vessel disease, and poor left ventricular function. Emergency CABG may be indicated for complications of ST-elevation myocardial infarction.

2. • CABG is performed for both symptomatic and
prognostic reasons
• Indications for CABG have been classified by the
ACC& AHA according to the level of evidence
supporting the usefulness and efficacy of the
procedure
• Class I - Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and
effective
• Class II - Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness or efficacy of a
procedure or treatment
• Class IIa - Weight of evidence or opinion is in favor of usefulness
or efficacy
• Class IIb - Usefulness or efficacy is less well established by
evidence or opinion
• Class III - Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful or effective,
and in some cases it may be harmful

3. Indication
Asymptoma
tic or Mild
Angina
Stable
Angina
Unstable
Angina/
NSTEMI
Poor LV
Functio
n
Left main
stenosis >50%
Class I Class I Class I Class I
Stenosis of
proximal LAD
and proximal
circumflex
>70%
Class I Class I Class I Class I
3-vessel
disease
Class I Class I
Class I,
with
proximal
LAD
stenosis
2-vessel
Class I if there is
large area of
viable
myocardium in
high-risk area
Class IIb

4. Indication
Asymptoma
tic or Mild
Angina
Stable
Angina
Unstable
Angina/
NSTEMI
Poor LV
Functio
n
With >70%
proximal LAD
stenosis
Class IIa
Class I with
either ejection
fraction < 50%
or demonstrable
ischemia on
noninvasive
testing
Class IIa Class I
Involving
proximal LAD
Class IIb
1-vessel
disease
Class I if there is
large area of
viable
myocardium in
high-risk area
Class IIa, if there
is viable
moderate area
Class IIb

5. Indication
Asymptoma
tic or Mild
Angina
Stable
Angina
Unstable
Angina/
NSTEMI
Poor LV
Functio
n
With >70%
proximal LAD
stenosis
Class IIa Class IIa Class IIa
Involving
proximal LAD
Class IIb

6. • Disabling angina (Class I)
• Ongoing ischemia in the setting of a non-
ST segment elevation myocardial infarction
that is unresponsive to medical therapy
(Class I)
• Poor left ventricular function but with
viable, nonfunctioning myocardium above
the anatomical defect that can be
revascularized

7. • CABG may be performed as an
emergency procedure in the context of a
STEMI in cases where it has not been
possible to perform PCI or where this
procedure has failed and there is
persistent pain and ischemia threatening a
significant area of myocardium despite
medical therapy

8. Other indications for CABG in the setting
of STEMI are:
• ventricular septal defect related to myocardial
infarction
• papillary muscle rupture
• free wall rupture
• ventricular pseudoaneurysm
• life-threatening ventricular arrhythmias, and
• cardiogenic shock

9. • [Guideline] Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR,
Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery
Bypass Graft Surgery: A Report of the American College of
Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. Circulation. 2011 Nov 7.[Medline]
• Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner
TJ. ACC/AHA 2004 guideline update for coronary artery bypass graft
surgery: summary article: a report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Update the 1999 Guidelines for Coronary
Artery Bypass Graft Surgery). Circulation. 2004 Aug 31. 110(9):1168-
76. [Medline]
• http://emedicine.medscape.com/article/1893992-overview#a3