Recently, the ACC, AHA, and SCAI have updated the 2011 coronary artery bypass grafting (CABG) guidelines. The latest available information on the newer guidelines and facts for indications of performing CABG is penned down in this article.

Coronary revascularisation

The history of coronary revascularisation has been amazingly stupendous and has revolved around evidence-based medicine over the last many decades. Both coronary-artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have evolved to present state-of-the-art treatment options for all facets of coronary artery disease (CAD). Central to this development of both procedures had been lively, intense and often fierce debate of superiority of one procedure over the other. Also, the ideal patient population most suited for a particular patient had also been debated, argued and contested over and over again.

CABG 

Despite all such ambiguities and conflicts of opinions, there had been two generally agreed patient populations where the clear edge of CABG over PCI has been accepted and recognised.

• Patients with a higher burden of disease and increasing lesion complexity
• Patients with diabetes mellitus

There had been expert guidelines from time to time regarding indications of CABG. These guidelines had been regularly updated time and again to accommodate newer clinical evidence that is being observed constantly.

Guidelines

Following are the key recommendations of the recent guidelines by the ACC, AHA, and SCAI.

1. It is important to recommend CABG based on clinical decisions regardless of sex, race, or ethnicity. It has been noted that women, blacks, Asians and lower socioeconomic strata patients are less advised surgery despite clear indications and available facilities. This inequality needs to be corrected.
2. A multidisciplinary “heart team” should be formed in each capable institution comprising experts from cardiovascular and allied fields. The decision of the team should be on clinical merit alone for patients who might benefit from CABG or when the optimal strategy is unclear. These patients fall in the grey zone in the middle of extreme indications for CABG and PCI. This includes most patients with multivessel CAD, left main disease, and diabetes, among others.
3. Left main disease needs to be vascularised with a sense of urgency depending upon clinical profile. CABG is recommended over PCI when high-complexity CAD is present. However, PCI is reasonable in selected patients if equivalent revascularisation is possible and the disease is less complex.
4. Recommendations are very clear that diabetic patients with multivessel CAD involving the left anterior descending artery should undergo CABG instead of PCI.
5. In selected patients who are post-surgery with stable CAD especially when they are at high bleeding risk, aspirin may be safely stopped in favour of P2Y12 monotherapy after 1 to 3 months.
6. The radial artery should be used as a conduit for the second most important graft during CABG.
7. Wherever possible total arterial revascularisation should be done and minimal access surgery is performed.

Role of drug treatment

Finally, a word about medical treatment as well! The role of drug treatment has witnessed a boost from the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA). This trial has shown no benefit of PCI or CABG over medical therapy in patients with coronary artery disease and moderate-to-severe ischemia. There had been much criticism of the approach, but nonetheless, the role of medical treatment should never be underemphasised. There is a definite patient subset that derives long-term benefits from this approach.

Disclaimer- The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of M3 India.

The author, Dr Arun Kochar is a Senior Interventional Cardiologist practising in Mohali.