Unstable angina non ST elevation myocardial infarction recommendations for CABG

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Smita Kohli, M.D. ; Arzu Kalayci, M.D. [2]

Overview

When revascularization is required for patients presenting with unstable angina or NSTEMI, the choice is between PCI and CABG. In general, the indications for PCI and CABG in UA/NSTEMI are similar to those for stable angina. Based on the results of multiple randomized trials, CABG is recommended for patients with disease of the left main coronary artery, multivessel disease and impaired left ventricular function. However, recent advances in techniques and less complications with PCI have led to use of PCI for isolated left main disease.

PCI versus CABG

Clinical Trial Data

More than nine trials have compared PCI and CABG in patients with ischemic heart disease, many of whom had UA/NSTEMI. The BARI and CABRI trials were two large major trials with head to head comparison of PCI versus CABG.

• The BARI trial, the largest randomized comparison of CABG and PTCA, was performed in 1,829 patients with 2- or 3-vessel CAD. Unstable angina was the admitting diagnosis in 64% of these patients, and 19% had treated diabetes mellitus. A majority of patients had two- rather than three-vessel disease (37% of patients had a proximal LAD lesion) and normal LV function. The subgroup of patients with treated diabetes had a significantly better survival rate with CABG. That survival advantage for CABG was focused in the group of diabetic patients with multiple severe lesions.
• The EAST trial, which was another trial in the US studying PCI versus CABG showed that patients with diabetes had an equivalent survival rate with CABG or PTCA at five years, after which the curves began to diverge but failed to reach a statistically significant difference at eight years (surgical survival 75.5%, PTCA 60.1%; p = 0.23).

In both BARI and EAST trials, the biggest differences in late outcomes were the need for repeat revascularization procedures and symptom status with 54% of PTCA patients undergoing subsequent revascularization procedures during the five-year follow-up versus 8% of the BARI CABG group and 13% of the EAST CABG group.

• The CABRI investigators also showed a survival benefit for CABG in patients with diabetes mellitus with multivessel.

• The SYNTAX trial, failed to show PCI to be noninferior to CABG in left main and triple-vessel disease. SYNTAX trial was an unblinded, randomized clinical trial that assigned patients with 3-vessel and/or left main CAD to an initial treatment strategy of CABG or PCI.The primary prespecified end point for the 1800 enrolled patients was the composite of death, stroke, and myocardial revascularization determined at 12 months. In SYNTAX, for the subgroup with left main CAD, there were no significant differences in the incidence of the composite end point (death, MI, stroke, or repeat revascularization) between the 2 groups, although rates of repeat revascularization were higher and rates of stroke were lower in the PCI group. Left main stented patients with limited CAD (lower SYNTAX score) displayed a trend toward fewer adverse events at 12 months than did similar patients assigned to CABG. This has led to change of recommendation for PCI as an alternative to CABG for left main disease from Class III in 2005 PCI guidelines to Class IIb in 2009 PCI guidelines. However, it should be kept in mind that the number of patients with left main disease in this study was relatively small and the follow up was of 1 year and longer follow up is needed before a decision is made to routinely recommend PCI for patients with isolated left main disease. The writing committee for the 2009 PCI updates clarifies that the Class IIb indication is intended to apply only to those left main lesions that are suitable for PCI. A follow up angiography after PCI of left main disease is no longer recommended.

Indications

• High-risk patients with LV systolic dysfunction, patients with diabetes mellitus, and those with 2-vessel disease with severe proximal LAD involvement or severe 3-vessel or left main disease should be considered for CABG.
• Low-risk patients will have negligibly increased chances of long-term survival with CABG (or PCI) and therefore should be managed medically. However, in low-risk patients, quality of life and patient preferences may be considered in addition to strict clinical outcomes in the selection of a treatment strategy.

ACC/AATS/AHA/ASE/ASNC/SCAI/ SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes

NSTEMI / Unstable Angina

Indication	Appropriate Use Score (1–9)
Revascularization by PCI or CABG
Evidence of cardiogenic shock - Immediate revascularization of 1 or more coronary arteries	A(9)
Patient stabilised - Intermediate OR high-risk features for clinical events (e.g., TIMI score 3–4) - Revascularization of 1 or more coronary arteries	A(7)
Patient stabilised after presentation - Low risk measures for clinical events (e.g., TIMI score ≤ 2) - Revascularization of 1 or more coronary arteries	M (5)
A = appropriate; CABG = coronary artery bypass graft; HF = heart failure; M = may be appropriate; PCI = percutaneous coronary intervention; R = rarely appropriate; STEMI = ST-segment elevation myocardial infarction. Median Score 7 to 9: Appropriate Care, Median Score 4 to 6: May Be Appropriate Care, Median Score 1 to 3: Rarely Appropriate Care

2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease

Recommendations for duration of DAPT in patients undergoing CABG

Class I

"1. In patients treated with DAPT after coronary stent implantation who subsequently undergo CABG, P2Y12 inhibitor therapy should be resumed postoperatively so that DAPT continues until the recommended duration of therapy is completed.(Level of Evidence: C-EO)"

"2. In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo CABG, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS(Level of Evidence: C-LD)"

"3. In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended(Level of Evidence: B-NR)"

Class IIb

"1. In patients with SIHD, DAPT (with clopidogrel initiated early postoperatively) for 12 months after CABG may be reasonable to improve vein graft patency (Level of Evidence: B-NR)"

Class III (No Benefit)

"1. In patients with SIHD without prior history of ACS, coronary stent implantation, or recent (within 12 months) CABG, treatment with DAPT is not beneficia (Level of Evidence: B-R)"

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT)

Class I

"1. Non–enteric-coated aspirin (81 mg to 325 mg daily) should be administered preoperatively to patients undergoing CABG. (Level of Evidence: B)"

"2. In patients referred for elective CABG, clopidogrel and ticagrelor should be discontinued for at least 5 days before surgery (Level of Evidence: B) and prasugrel for at least 7 days before surgery. (Level of Evidence: C)"

"3. In patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours to reduce major bleeding. (Level of Evidence: B)"

"4. In patients referred for CABG, short-acting intravenous GP IIb/IIIa inhibitors (eptifibatide or tirofiban) should be discontinued for at least 2 to 4 hours before surgery and abciximab for at least 12 hours before to limit blood loss and transfusion. (Level of Evidence: B)"

Class IIb

"1. In patients referred for urgent CABG, it may be reasonable to perform surgery less than 5 days after clopidogrel or ticagrelor has been discontinued and less than 7 days after prasugrel has been discontinued. (Level of Evidence: C)"

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)

CABG (DO NOT EDIT)

Class I

"1. Coronary artery bypass graft surgery is recommended for UA / NSTEMI patients with significant left main CAD (>50% stenosis). (Level of Evidence: A)"

"2. Coronary artery bypass graft surgery is recommended for UA / NSTEMI patients with 3-vessel disease; the survival benefit is greater in patients with abnormal LV function (LVEF<50%). (Level of Evidence: A)"

"3. Coronary artery bypass graft surgery is recommended for UA / NSTEMI patients with 2 vessel disease with significant proximal LAD disease and either abnormal LV function (LVEF <50%) or ischemia on non invasive testing. (Level of Evidence: A)"

"4. Coronary artery bypass graft surgery is recommended for UA / NSTEMI patients in whom percutaneous coronary revascularization is not optimal or possible and who have ongoing ischemia not responsive to maximal nonsurgical therapy. (Level of Evidence: B)"

"5. Coronary artery bypass graft surgery (or PCI) is recommended for UA / NSTEMI patients with 1 or 2 vessel CAD with or without significant proximal left anterior descending CAD but with a large area of viable myocardium and high risk criteria on noninvasive testing. (Level of Evidence: B)"

"6. Coronary artery bypass graft surgery (or PCI) is recommended for UA / NSTEMI patients with multivessel coronary disease with suitable coronary anatomy, with normal LV function, and without diabetes mellitus. (Level of Evidence: A)"

Class III

"1. Coronary artery bypass graft surgery (or PCI) is not recommended for patients with 1- or 2-vessel CAD without significant proximal left anterior descending CAD without current symptoms or symptoms that are unlikely to be due to myocardial ischemia and who have no ischemia on non invasive testing. (Level of Evidence: C)"

Class IIa

"1. For patients with UA / NSTEMI and multi vessel disease, CABG with use of the internal mammary arteries can be beneficial over PCI in patients being treated for diabetes. (Level of Evidence: B)"

"2. It is reasonable to perform CABG with the internal mammary artery for UA / NSTEMI patients with multi vessel disease and treated diabetes mellitus. (Level of Evidence: B)"

"3. Repeat CABG is reasonable for UA / NSTEMI patients with multiple SVG stenoses, especially when there is significant stenosis of a graft that supplies the LAD. (Level of Evidence: C)"

"4. Coronary artery bypass graft surgery (or PCI) is reasonable for UA / NSTEMI patients with 1 or 2 vessel CAD with or without significant proximal left anterior descending CAD but with a moderate area of viable myocardium and ischemia on non invasive testing. (Level of Evidence: B)"

"5. Coronary artery bypass graft surgery (or PCI) can be beneficial compared with medical therapy for UA / NSTEMI patients with 1 vessel disease with significant proximal left anterior descending CAD. (Level of Evidence: B)"

"6. Coronary artery bypass surgery (or PCI with stenting) is reasonable for patients with multi vessel disease and symptomatic myocardial ischemia. (Level of Evidence: B)"

Class IIb

"1. Coronary artery bypass graft surgery may be considered in patients with UA / NSTEMI who have 1 or 2 vessel disease not involving the proximal LAD with a modest area of ischemic myocardium when percutaneous revascularization is not optimal or possible. (If there is a large area of viable myocardium and high-risk criteria on non invasive testing, this recommendation becomes a Class I recommendation.) (Level of Evidence: B)"