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Re-evaluating the Role of CABG in Acute Coronary Syndromes

Current Cardiology Reports volume 22, Article number: 148 (2020) Cite this article

Abstract

Purpose of Review

The use of coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS) has markedly declined during the past decade, with an increase in the use of percutaneous coronary intervention (PCI). However, long-term data continues to show survival advantages for patients undergoing CABG over PCI. We describe the current indications for and outcomes of CABG in patients who present with ACS.

Recent Findings

Real-world studies demonstrate better long-term outcomes with CABG than with PCI after NSTE-ACS. Staged CABG after culprit-vessel PCI for STEMI is also a feasible option in certain patients. In patients presenting with ACS and cardiogenic shock who are treated with CABG, the use of mechanical circulatory support has produced a limited but significant reduction in mortality.

Summary

The optimal revascularization strategy after ACS depends on many variables. The pre-eminent factor in selecting the best mode of revascularization and improving outcomes is careful patient selection based on deliberation by an interdisciplinary heart team.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;64:e139–228.

    Article  Google Scholar 

  2. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 appropriate use criteria for coronary revascularization in patients with acute coronary syndromes: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2017;69:570–91.

    Article  Google Scholar 

  3. Thiele H, Akin I, Sandri M, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med. 2017;377:2419–32.

    Article  Google Scholar 

  4. Patel S, Bailey SR. Revascularization strategies in STEMI with multivessel disease: deciding on culprit versus complete—ad hoc or staged. Curr Cardiol Rep. 2017;19:93.

    Article  Google Scholar 

  5. Burgess SN, French JK, Nguyen TL, et al. The impact of incomplete revascularization on early and late outcomes in ST-elevation myocardial infarction. Am Heart J. 2018;205:31–41.

    Article  Google Scholar 

  6. Mehta SR, Wood DA, Storey RF, et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019;381:1411–21.

    Article  Google Scholar 

  7. Rodriguez-Olivares R, Lopez-Menendez J, Barca LV, et al. Identification of candidates for coronary artery bypass grafting admitted with STEMI and multivessel disease. Cardiovasc Revasc Med. 2018;19:21–6.

    Article  Google Scholar 

  8. Polito MV, Asparago S, Galasso G, et al. Early myocardial surgical revascularization after ST segment elevation myocardial infarction in multivessel coronary disease: bridge therapy is the solution? J Cardiovasc Med (Hagerstown). 2018;19:120–5.

    Article  Google Scholar 

  9. Desperak P, Hawranek M, Hrapkowicz T, et al. Comparison of multivessel percutaneous coronary intervention and coronary artery bypass grafting in patients with severe coronary artery disease presenting with non-ST segment elevation acute coronary syndromes. Kardiol Pol. 2018;76:1474–81.

    Article  Google Scholar 

  10. Klempfner R, Barac YD, Younis A, et al. Early referral to coronary artery bypass grafting following acute coronary syndrome, trends and outcomes from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000–2010. Heart Lung Circ. 2018;27:175–82.

    Article  Google Scholar 

  11. Head SJ, Davierwala PM, Serruys PW, et al. Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial. Eur Heart J. 2014;35:2821–30.

    CAS  Article  Google Scholar 

  12. •• Chang M, Lee CW, Ahn JM, et al. Comparison of outcome of coronary artery bypass grafting versus drug-eluting stent implantation for non-ST-elevation acute coronary syndrome. Am J Cardiol. 2017;120:380–6. Pooled analysis of NSTE-ACS cohorts from 3 major randomized trials showing less frequent composite of death, MI, and stroke after CABG compared to PCI.

  13. Park SJ, Ahn JM, Kim YH, et al. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med. 2015;372:1204–12.

    CAS  Article  Google Scholar 

  14. Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011;364:1718–27.

    CAS  Article  Google Scholar 

  15. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961–72.

    CAS  Article  Google Scholar 

  16. Desperak P, Hawranek M, Gasior P, et al. Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST segment elevation acute coronary syndromes. Cardiol J. 2019;26:157–68.

    PubMed  Google Scholar 

  17. Shiyovich A, Shlomo N, Cohen T, et al. Temporal trends of patients with acute coronary syndrome and multi-vessel coronary artery disease-from the ACSIS registry. Int J Cardiol. 2020;304:8–13.

    Article  Google Scholar 

  18. • Ram E, Sternik L, Klempfner R, et al. Outcomes of different revascularization strategies among patients presenting with acute coronary syndromes without ST elevation. J Thorac Cardiovasc Surg. 2019. Real-world outcomes from a national database showing improved 10-year survival for patients who were treated with CABG after NSTE-ACS compared to PCI.

  19. Huckaby LV, Sultan I, Mulukutla S, et al. Revascularization following non-ST elevation myocardial infarction in multivessel coronary disease. J Card Surg. 2020;35:1195.

    Article  Google Scholar 

  20. Parikh SV, de Lemos JA, Jessen ME, et al. Timing of in-hospital coronary artery bypass graft surgery for non-ST segment elevation myocardial infarction patients results from the National Cardiovascular Data Registry ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines). JACC Cardiovasc Interv. 2010;3:419–27.

    Article  Google Scholar 

  21. Rojas SV, Trinh-Adams ML, Uribarri A, et al. Early surgical myocardial revascularization in non-ST segment elevation acute coronary syndrome. J Thorac Dis. 2019;11:4444–52.

    Article  Google Scholar 

  22. Bianco V, Kilic A, Gleason TG, et al. Timing of coronary artery bypass grafting after acute myocardial infarction may not influence mortality and readmissions. J Thorac Cardiovasc Surg. 2019.

  23. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375–84.

    CAS  Article  Google Scholar 

  24. Farkouh ME, Domanski M, Dangas GD, et al. Long-term survival following multivessel revascularization in patients with diabetes: the FREEDOM follow-on study. J Am Coll Cardiol. 2019;73:629–38.

    Article  Google Scholar 

  25. Ramanathan K, Abel JG, Park JE, et al. Surgical versus percutaneous coronary revascularization in patients with diabetes and acute coronary syndromes. J Am Coll Cardiol. 2017;70:2995–3006.

    Article  Google Scholar 

  26. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA. 2006;295:2511–5.

    Article  Google Scholar 

  27. White HD, Assmann SF, Sanborn TA, et al. Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial. Circulation. 2005;112:1992–2001.

    Article  Google Scholar 

  28. Smilowitz NR, Alviar CL, Katz SD, Hochman JS. Coronary artery bypass grafting versus percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock. Am Heart J. 2020;S0002–8703(20):30080–6 Epub ahead of print.

    Google Scholar 

  29. Chiu FC, Chang SN, Lin JW, et al. Coronary artery bypass graft surgery provides better survival in patients with acute coronary syndrome or ST segment elevation myocardial infarction experiencing cardiogenic shock after percutaneous coronary intervention: a propensity score analysis. J Thorac Cardiovasc Surg. 2009;138:1326–30.

    Article  Google Scholar 

  30. Acharya D, Gulack BC, Loyaga-Rendon RY, et al. Clinical characteristics and outcomes of patients with myocardial infarction and cardiogenic shock undergoing coronary artery bypass surgery: data from the Society of Thoracic Surgeons National Database. Ann Thorac Surg. 2016;101:558–66.

    Article  Google Scholar 

  31. Acharya D, Loyaga-Rendon RY, Pamboukian SV, et al. Ventricular assist device in acute myocardial infarction. J Am Coll Cardiol. 2016;67:1871–80.

    Article  Google Scholar 

  32. Elbadawi A, Elgendy IT, Mahmoud K, et al. Temporal trends and outcomes of mechanical complications in patients with acute myocardial infarction. J Am Coll Cardiol Intv. 2019;12:1825–36.

    Article  Google Scholar 

  33. French JK, Hellkamp AS, Armstrong PW, et al. Mechanical complications after percutaneous coronary intervention in ST-elevation myocardial infarction (from APEX-AMI). Am J Cardiol. 2010;105:59–63.

    Article  Google Scholar 

  34. Deo SV, Dunlay SM, Shah IK, et al. Dual anti-platelet therapy after coronary artery bypass grafting: is there any benefit? A systematic review and meta-analysis. J Card Surg. 2013;28:109–16.

    Article  Google Scholar 

  35. Une D, Al-Atassi T, Kulik A, et al. Impact of clopidogrel plus aspirin versus aspirin alone on the progression of native coronary artery disease after bypass surgery: analysis from the Clopidogrel After Surgery for Coronary Artery DiseasE (CASCADE) randomized trial. Circulation. 2014;130:S12–8.

    CAS  Article  Google Scholar 

  36. Ferraris VA, Saha SP, Oestreich JH, et al. 2012 Update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients having cardiac and noncardiac operations. Ann Thorac Surg. 2012;94:1761–81.

    Article  Google Scholar 

  37. Rossini R, Tarantini G, Musumeci G, et al. A multidisciplinary approach on the perioperative antithrombotic management of patients with coronary stents undergoing surgery: Surgery after Stenting 2. JACC Cardiovasc Interv. 2018;11:417–34.

    Article  Google Scholar 

  38. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016;134:e123–55.

    Article  Google Scholar 

  39. • Gupta S, Belley-Cote EP, Agahi P, et al. Antiplatelet therapy and coronary artery bypass grafting: analysis of current evidence with a focus on acute coronary syndrome. Can J Cardiol. 2019;35:1030–8. Contemporary review of current guidelines and the most recent literature on antiplatelet therapy for CABG in the setting of ACS.

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Affiliations

  1. Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA

    Douglas Farmer & Ernesto Jimenez

  2. Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA

    Douglas Farmer & Ernesto Jimenez

  3. Division of Cardiothoracic Surgery, Michael E. DeBakey VA Medical Center, Houston, TX, USA

    Douglas Farmer & Ernesto Jimenez

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  1. Douglas Farmer
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  2. Ernesto Jimenez
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Correspondence to Douglas Farmer.

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This article is part of the Topical Collection on Management of Acute Coronary Syndromes

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Farmer, D., Jimenez, E. Re-evaluating the Role of CABG in Acute Coronary Syndromes. Curr Cardiol Rep 22, 148 (2020). https://doi.org/10.1007/s11886-020-01386-y

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Keywords

  • Acute coronary syndrome
  • CABG
  • Percutaneous interventions