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SECTION 2 Treatment ofcoronary artery disease
discontinuation of the medications. In general, lower doses of the
statins are better tolerated than high doses; alternatively, in some
patients, myalgias are drug specic and therapy with a change in the
specic drug used may improve symptoms and allow resumption of
erapy must be individualized and typically includes multiple
agents keeping in mind the potential for drug– drug interactions.
As comorbidities are very common, a multifaceted approach is
required.
compliance with statin treatment.
ere are a number of other agents which are felt to be adjunctive
to statins (Table 11.1) and are used with a specic LDL- C goal if
Exercise andrehabilitation
not achieved with the statin. Some information on specic agents
such as ezetimibe has been found to be associated with a moderate
reduction in cardiovascular events. However, these other agents are
typically used as adjunctive therapy.
An important new approach is the introduction of pro- protein
convertase subtilisin kexin- 9 (PCSK9) antibodies which result in
marked decreases in LDL- C by approximately 40% in addition to
statins.– ese agents are still infrequently used because of extremely high cost. e direct relationship between the magnitude of
reduction in LDL- C and longer- term clinical endpoints continues to
be the focus of large- scale studies. Recent data from the large randomized FOURIER trial of 27,564 patients with cardiovascular
disease and on a moderate- to high- intensity statin documented that
the addition of PCSK9 antibodies was associated with a 15% reduction in the primary composite endpoint of myocardial infarction,
stroke, hospitalization for angina, revascularization, or cardiovascular death. Aer the rst year of treatment, there was a 25% reduction in the composite endpoint of cardiovascular death, myocardial
infarction, or stroke. e median LDL- C concentration was reduced
by 59% to 30 mg/ dL.
Diabetes
Given the high incidence of diabetes in patients with cardiovascular disease, medical management is of great importance particularly given the fact that diabetes exacerbates the pathophysiology
of atherosclerosis and congestive heart failure.,,– Given the
coexistent comorbidities of obesity, hypertension, and hyperlipidaemia, multifactorial risk treatment strategies are needed. e eect
of glycaemic control on outcome has been the subject of multiple
studies. ere have been variable results reported in terms of the
eect of diabetes on macrovascular events. e need for very aggressive glycaemic control was assessed in the ACCORD trial, which
was stopped early because of increased mortality in the aggressive
treatment group.
e role of hyperinsulinaemia and insulin resistance in type 2
diabetes has been stressed. Risk factor modication with diet, exercise, and amelioration of obesity can help in this regard but medial
therapy remains very common. Metformin remains the cornerstone and is typically the agent of rst choice for secondary prevention. Other strategies include targeting insulin resistance using
pioglitazone, which has been shown to reduce the rate of stroke and
e lack of regular physical activity (Box 11.2) has been identied
as a signicant risk factor for cardiovascular disease.– An analysis of the eect of physical inactivity on major non- communicable
diseases worldwide documented that it contributes 6% of cardiovascular disease worldwide. ere are multiple positive eects
of regular physical activity, including a variety of antiatherogenic,
antithrombotic, and psychological eects. Regular physical activity
also is associated with improved blood pressure and weight control
as well as improved lipids. Guidelines on this specic strategy recommend for adults an average of 40 minutes of at least moderate
intensity activity four to ve times per week. ese strategies require
multiple dierent action items involving the individual, family,
school, and workplace to be maximally eective. ey must be carried out at regional levels, understanding regional behaviour patterns and concerns. Some aspects of this strategy will uniquely relate
to patients with a recent index event, but the general principles remain relevant.
In patients with overt clinically apparent cardiovascular disease,
following an acute event, the importance of cardiac rehabilitation
has been emphasized. Societal guidelines have been developed particularly for those patients with an acute coronary syndrome, recent
myocardial revascularization, and recent congestive heart failure.
Rehabilitation programmes are also helpful for patients with stable
angina (Box 11.2). e eects of this were evaluated in a metaanalysis of 63 trials which included 14,486 patients following either
myocardial infarction or revascularization who were randomly assigned to either exercise cardiac rehabilitation or control. e authors found that patients undergoing rehabilitation had a lower risk
of cardiovascular death (relative risk (RR) 0.74, 95% CI 0.64– 0.86)
but no signicant dierence in all- cause death or revascularization.
ere was a lower risk of hospital readmission (RR 0.82, 95% CI
0.70– 0.96).
In a single- centre, county- based registry of 2400 patients who
had undergone PCI, patients enrolled in cardiac rehabilitation had
an approximately 50% reduction in all- cause mortality at 5years.
An important component of cardiac rehabilitation programmes
includes instruction in risk factor management such as tobacco
abstinence, medication management, and diet. However, despite
endorsement by professional societal guidelines, many patients are
either not enrolled in or do not attend cardiovascular rehabilitation.
myocardial infarction.
Insulin- sparing versus insulin provisional strategies have been
studied in both randomized controlled trials and registries. While
early concerns were raised about the safety of insulin, they have not
been subsequently substantiated. Very aggressive strategies to target
blood sugar have been found to result in clinical problems with
hypoglycaemia and even increased mortality. However, insulin
therapy is oen needed to reach a target goal of HbA1c less than or
equal to 7.0%. If hypoglycaemia remains a problem, a less intensive
goal of 7.5% or lower is oen selected.
Box 11.2 Indications forcardiacrehabilitation
• Acute MI within the preceding 12months
• Coronary revascularization either with CABG or PCI
• Stable angina
• Heart valve replacement
• Chronic heart failure
• Heart or heart lung transplantation.
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Alternatives to on- site cardiac rehabilitation programmes are available, including a variety of patient educational materials which have
been adapted to cell phones. Whether adherence to these alternatives results in the same improvement in patient outcomes as seen
with structured programmes is unclear.
e timing of cardiovascular rehabilitation has important implications for longer- term compliance. Adelay in initiation has been
found to be an independent predictor of diminished improvement
in cardiovascular tness. Risk stratication guidelines have been
developed by the American Heart Association with four dierent
classications ranging from individuals who are apparently healthy
to those with unstable disease. e goal of all formal rehabilitation
programmes is to ‘graduate’ the patient to participation in regular
physical activity along with lifestyle modication indenitely.
Components of any exercise programme include warm- up exercises comprising stretching and exibility movements lasting
for 5– 10 minutes, then aerobic activity for continued training. e
specic level of intensity can be recommended as part of an exercise prescription. e aerobic portion typically lasts 30– 45 minutes and then is followed by a cool- down recovery period, again of
5– 10 minutes. For some exercise prescriptions, a target heart range
is determined and recommended; for others, perceived ranges of
level of exercise are used. e three components of warm up, exercise, and then cool down are essential for optimizing results and
minimizing unintended consequences such as musculoskeletal injuries. e goal should be ve times per week. Compliance with
an exercise programme has the associated benets of improved
hypertension control, weight reduction with decreased obesity,
better glycaemic control, as well as improvement in psychosocial
An individual patient data meta- analysis of ten randomized trials
showed a signicant interaction between body weight and aspirin
eect at dierent dosage, highlighting the importance of individualization of the treatment.
Secondaryprevention
erapeutic regimens for secondary prevention vary substantially based upon the specic patient population, the specic presenting clinical issue, and the time elapsed from the index event.–
Additional considerations include the presence of comorbidities
such as atrial brillation. Aspirin remains a mainstay of secondary
prevention.
Stable patients undergoing elective PCI should receive aspirin
and a P2Y receptor blocker (Box 11.3). e most commonly re-
commended aspirin dose is 100 mg or less four times per day and
should be continued indenitely. ere are three P2Y receptor
blocker agents— clopidogrel, ticagrelor, and prasugrel. e usual
goal of dual antiplatelet therapy (DAPT) is to reduce the incidence
of stent thrombosis. Limited data suggests that DAPT may also
improve gra patency aer surgical coronary revascularization.
Clinical practices vary as to the selection of specic P2Y agents.
ere are issues of drug resistance, side eects, and costs which may
be considered. Recommendations for the duration of therapy continue to evolve. European practices in general have identied that in
stable patients with less complex disease, 3– 6months of DAPT are
satisfactory following which aspirin is continued indenitely. In the
United States, 6– 12months is more generally accepted, particularly
with drug- eluting stents and particularly in patients at higher risk
for stent thrombosis.
behaviour patterns.
Antiplatelet and anticoagulantstrategies
Antiplatelet and anticoagulant strategies for either primary or secondary prevention of cardiovascular disease continue to evolve with
the completion of randomized clinical trials. e goals of therapy
depend greatly on the specic anatomical and clinical subset of
patients.
Primaryprevention
Aspirin has long been considered an important part of primary
prevention. A recent systematic evidence- based review focused
on trials using aspirin for primary prevention of cardiovascular
events. e authors identied 11 randomized controlled trials that
included 118,445 participants. ere was variability in the trials between the dosage of aspirin as well as the specic endpoints, which
ranged from non- fatal myocardial infarction or stroke to cardiovascular disease mortality or even all- cause mortality. Important ndings were as follows:
1. Aspirin reduced the risk for non- fatal myocardial infarction (RR
0.78, 95% CI 0.71– 0.87).
2. ere was little benet for either all- cause or cardiovascular-
specic death that could be attributable to aspirin.
3. Benets occurred within 5years of treatment.
4. In trials with a dose of aspirin of 100 mg or less per day, the re-
duction in non- fatal myocardial infarction was retained.
Box 11.3 Updated guidelines onDAPT inpatients treated
withPCI
• Intensification of antiplatelet therapy, with the addition of a P2Y in-
hibitor to aspirin monotherapy requires a thoughtful assessment of
the benefit:risk ratio, integration of study data, and consideration of
patient preference.
• Shorter- duration DAPT can be considered for patients at lower is-
chaemic risk with high bleeding risk, whereas longer- duration DAPT
may be reasonable in the setting of higher ischaemic risk with lower
bleeding risk.
• Newer- generation stents have an improved safety profile and lower
risk of stent thrombosis.
• Updated recommendations for duration of DAPT are now similar for
patients with non- ST- segment elevation acute coronary syndrome
and ST- segment elevation acute coronary syndrome, as both are part
of the spectrum of acute coronary syndrome.
• AclassIrecommendation in most clinical settings is made for at least
6– 12months of DAPT, and a classIIb recommendation for prolonged
DAPT beyond this initial 6– 12- month period. In patients for whom
the benefit:risk ratio seemingly favours prolonged therapy, the true
optimal duration of therapy is unknown. Aspirin therapy should almost always be continued indefinitely in patients with coronary artery
disease.
• Lower daily doses of aspirin, including in patients treated with DAPT,
are associated with lower bleeding complications and comparable
ischaemic protection than are higher doses of aspirin. The recommended daily dose of aspirin in patients treated with DAPT is 81 mg
(range:75– 100 mg).
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SECTION 2 Treatment ofcoronary artery disease
An important confounding issue relates to the clinical indication
for anticoagulation. Up to 10% of patients undergoing coronary artery stenting have an indication for anticoagulation, which is typically for the prevention of stroke in the setting of non- valvular
atrial brillation. Triple therapy in such patients is associated with
a marked increase in bleeding. Multiple potential approaches have
been evaluated to decrease the bleeding hazard but also protect the
patient against stent thrombosis. Considerations include (1) the
duration of triple therapy, (2)the specic medications for therapy,
(3)the clinical indication for the triple therapy, and (4)the potential
for other approaches for treatment. In patients with atrial brillation
and a high predicted risk of stroke as well as bleeding, placement of
the le atrial appendage occlusion device can eliminate the need for
anticoagulation leaving only DAPT to be considered.
e duration and specic agents used has been evaluated. An
open label randomized trial (WOEST) studied this question in
573 patients who were on oral anticoagulation therapy. e patients
were randomized to either anticoagulant therapy plus clopidogrel
or anticoagulant therapy plus aspirin plus clopidogrel. ey conrmed that triple therapy was accompanied by signicant increases
in bleeding which was the primary endpoint. e combined secondary endpoint of death, myocardial infarction, stroke, targetvessel revascularization, and stent thrombosis was lower with
clopidogrel plus oral anticoagulation (11.1 vs 17.6%, HR 0.56, 95%
CI 0.35– 0.91). Despite the small size of this trial, it has had a substantial impact on clinical practice. In many practices for patients
receiving oral anticoagulation undergoing stenting, they are treated
with triple therapy for 30days and then the aspirin is discontinued,
leaving the patient on oral anticoagulation and a P2Y inhibitor.
Typically, in this setting, clopidogrel is the more commonly used
P2Y inhibitor.
Direct oral anticoagulants have also been studied in this setting.
e PIONEER AF trial evaluated the use of rivaroxaban in 2124
patients with non- valvular atrial brillation who had undergone
PCI with stenting. ree regimens were studied:(1) dose- adjusted
vitamin K antagonists plus DAPT (usually clopidogrel) for 1, 6, or
12months; (2)low- dose rivaroxaban (15 mg four times daily) plus
Secondary therapy aer CABG with antiplatelet agents as well
as optimal statins plays a mainstay role as in other high- risk patients for secondary prevention. e importance of smoking cessation as well as cardiac rehabilitation has been emphasized and
is extremely important as documented previously in addition to
aggressive control of hypertension, diabetes, control of diabetes,
and cardiac rehabilitation.,, All patients should be enrolled in
a structured rehabilitation programme postoperatively and then
encouraged to maintain their exercise programmes indenitely.
Beta blockers may reduce the incidence of atrial arrhythmias in
the postoperative period and are part of the long- term secondary
prevention.
Antiplatelet therapy is of importance for prevention of further
cardiovascular events aer CABG, but also because it has been
shown to help maintain long- term vein gra patency. e large
Veterans Administration Cooperative Study randomized 772 patients undergoing CABG and studied the eect of dierent ASA
regimens on vein gra patency. In a 1- year assessment of gra patency, it found that ASA was associated with improved vein gra
patency. e study evaluated three dierent regimens:ASA 325 mg
four times daily, 325 mg three times daily, and ASA 325 mg in combination with dipyridamole. Irrespective of ASA dose the patency
was improved. Accordingly, these current guidelines recommend
325 mg four times daily rather than the more usual dose of 81 mg
four times daily. An unresolved issue relates to the administration of
P2Y inhibitors. ese agents have been typically used in the management of acute coronary syndromes and particularly in patients
undergoing coronary stenting. In patients undergoing CABG for an
acute ischaemic syndrome, continued administration of clopidogrel
for the acute ischaemic syndrome appears to be benecial. e role
of DAPT to improve vein gra patency is unresolved. ere have
been conicting results in both randomized clinical trials as well as
in the meta- analyses published. Some authors have concluded that
clopidogrel and ASA may be helpful to improve gra patency in the
setting of o- pump CABG although it is associated with increased
risk of bleeding.– e recommendations from this recent guideline are presented in Box 11.4.
a P2Y inhibitor (usually clopidogrel) for 12months; and (3)very
low- dose rivaroxaban (2.5 mg twice daily) plus DAPT for 1, 6, or
12months. Clinically signicant bleeding which was the primary
Conclusion
endpoint occurred signicantly less oen in the patients treated
with rivaroxaban. e rates of the composite of cardiovascular
death, myocardial infarction, or stroke were similar. Given these
data, low- dose rivaroxaban (15 mg four times daily) plus clopidogrel
for 12months is used with increasing frequency.
Coronary surgical revascularization remains the mainstay for
the treatment of patients with extensive multivessel disease and
particularly those with le ventricular dysfunction. ese are patients who are at the highest risk for recurrent cardiovascular events.
Accordingly, secondary prevention is extremely important.–
In the past, in contrast to patients treated with PCI, post- surgical
patients have not been treated as aggressively. A 2015 Scientic
Statement from the American Heart Association emphasizes the importance of secondary prevention in these patients who continue
to be at risk for subsequent ischaemic events. is is the result of the
underlying extensive coronary artery disease, but also the fact that
vein gras are also subject to progressive disease with vein gra occlusion related to atherothrombosis.
Cardiovascular disease is the major leading cause of death and disability worldwide. ere is increasing available data on common risk
factors, many of which are modiable; successful mitigation against
these risk factors could have a dramatic impact on cardiovascular
health worldwide. Global abstinence from tobacco, sustained control
of hypertension, and modication of lifestyle to increase physical activity and reduce obesity (which would help to curb the accelerating
prevalence of diabetes), could be associated with a greater than 50%
reduction in cardiovascular deaths worldwide.
An increasing amount of information is available on the benets
of both primary and secondary prevention of cardiovascular disease. In addition to improved quality of life and reduction in subsequent myocardial infarction, there is also a reduction in mortality
in selected patient subsets. Eorts continue to implement preventive
strategies on a global basis with attention to development of approaches to enhance patient compliance. Individual, as well as societal initiatives must be encouraged.
11 Optimal medical therapy for coronary arterydisease 111
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Box 11.4 Antiplatelet therapy recommendations inpatients
undergoingCABG
1. Aspirin should be administered preoperatively and within 6 hours
after CABG in doses of 81– 325 mg daily. It should then be continued
indefinitely to reduce graft occlusion and adverse cardiac events
(classI; level of evidence A).
2. After off- pump CABG, DAPT should be administered for 1year with
combined aspirin (81– 162 mg daily) and clopidogrel 75 mg daily to
reduce graft occlusion (classI; level of evidence A).
3. Clopidogrel 75 mg daily is a reasonable alternative after CABG for
patients who are intolerant of or allergic to aspirin. It is reasonable to
continue it indefinitely (classIIa; level of evidence C).
4. In patients who present with acute coronary syndromes, it is reason-
able to administer combination antiplatelet therapy after CABG with
aspirin and either prasugrel or ticagrelor (preferred over clopidogrel),
although prospective clinical trial data from CABG populations are
not yet available (classIIa; level of evidence B).
5. As sole antiplatelet therapy after CABG, it is reasonable to consider a
higher aspirin dose (325 mg daily) rather than a lower aspirin dose (81
mg daily), presumably to prevent aspirin resistance, but the benefits
are not well established (classIIa; level of evidence A).
6. Combination therapy with both aspirin and clopidogrel for 1year
after on- pump CABG may be considered in patients without recent
acute coronary syndrome, but the benefits are not well established
(classIIb; level of evidence A).
Source data from Aranki S, Aroesty JM. Medical therapy to prevent complications
after coronary artery bypass graft surgery. http:// www.uptodate.com accessed 4
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12
Differences and similarities
betweenAmerican and European
myocardial revascularizationguidelines
Milan Milojevic, Philippe Kolh, Stephen E. Fremes, and Miguel Sousa- Uva
Introduction
e development and update of clinical guidelines are based on
an evaluation of the latest data from clinical studies. According
to the National Academy of Medicine, clinical practice guidelines are ‘statements that include recommendations intended to
optimize patient care that is informed by a systematic review of
the evidence and an assessment of the benets and harms of alternative care options’. ese expert documents are intended to
provide systematically developed statements that include recommendations on how to translate clinical knowledge from scientic evidence into best patient- centred, evidence- based practice.
Supplementing the textbook, clinical guidelines are now being
increasingly considered decision drivers, and are being used by
healthcare providers to choose the most appropriate diagnostic
or therapeutic managing strategy, standardize care, reduce variation, and improve outcomes. e core of each of the clinical practice guidelines are the recommendations developed according to
an established scale of the hierarchy of evidence. Although randomized controlled trials (RCTs) are at the top of the pyramid of
evidence as the preferred study design for assessing the eects of
two or more interventions, in many instances, task force members must rely on ndings from observational studies. is is particularly so as trial patients may not always be typical of routine
clinical practice. Hence, valuable information can be obtained
from both RCTs and observational studies, including subgroup
analysis, cohorts, or case series; therefore, each type of scientic
research can be a signicant complement to the other and contribute to guideline developments.
Guidelines cannot cover all clinical scenarios- and the nal
decision remains with the treating physician or multidisciplinary healthcare team in agreement with the patient’s preference. Another value that guidelines add is the identication of
essential gaps in knowledge, oering direction for future research.
Importantly, clinical guidelines are not infallible, and several
limitations must be recognized. In the real- world setting, recommendations may depend on the task force composition, potential
intellectual biases, insucient data, and dierent interpretations
of existing evidence. is results in a frequently occurring but
highly undesirable phenomenon:recommendations that address
particular clinical problems receive dierent treatment propositions and/ or levels of certainty (evidence) by two dierent task
force groups. Noteworthy examples are two recently published recommendations from the United States by the American College
of Cardiology (ACC)/ American Heart Association (AHA), which
recommend dierent thresholds of ascending aortic dilatation that
would justify surgical intervention.
e 2018 European Society of Cardiology (ESC)/ European
Association for Cardio- oracic Surgery (EACTS) Guidelines on
myocardial revascularization address optimal revascularization
strategies in a single expert document, whereas the AHA/ ACC
issued two separate focus documents on coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) in 2011,, albeit with harmonized recommendations
for revascularization. Moreover, several overlapping guidelines
that cover dierent aspects of bypass surgery have been published on both continents. ese include the 2012 ACC/ AHA/
American Association for oracic Surgery (AATS)/ Preventive
Cardiovascular Nurses Association (PCNA)/ Society for
Cardiovascular Angiography and Interventions (SCAI)/ Society of
oracic Surgeons (STS) Guidelines for the diagnosis and management of patients with stable ischaemic heart disease, followed
by a focused update in 2014,, and the 2013 ESC Guidelines on
the management of stable coronary artery disease (CAD) by the
European societies. More recently, the STS has published guidelines on arterial conduits for CABG. It should be noted that
American and European representative societies operate in different legal, cultural, and political environments and have developed various strategies to match those circumstances. In Europe,
several organizations of non- interventional and interventional
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SECTION 2 Treatment ofcoronary artery disease
cardiologists, surgeons, nurses, clinical perfusionists, and allied
health practitioners are aliated in two large societies, the ESC
and the EACTS, mainly according to their clinical roles. In contrast, in the United States, healthcare professionals are diverted
into multiple specialty societies related to cardiology, cardiac surgery, and nursing. Depending on the topic of joint initiative and
the strength of scientic evidence, these structural dierences may
play a signicant role in the development of clinical guidelines.
Moreover, any comparison between the two guidelines needs to
take into account the time dierence of their publications. Despite
these limitations, we have concentrated our analysis of dierences
and similarities between the 2011 ACC/ AHA Guidelines, and the
2018 ESC/ EACTS Guidelines on myocardial revascularization,
especially technical aspects of CABG and the choice of preferred
revascularization interventions in specic groups of patients with
stable CAD.
and cardiac surgeon, with other specialists as needed. e purpose
of the Heart Team is to identify the most appropriate treatment for
the particular patient and help patients and their families to reach
the best treatment choice. A‘Heart Team approach’ holds a classIC
recommendation. Furthermore, the ESC/ EACTS Guidelines highly
recommend the development of institutional protocols to identify
complex cases and postpone revascularization at the time of diagnostic angiography. ese protocols are aimed at enabling ‘Heart
Team’ discussions to prevent physician- related bias and to recommend the most optimal procedural aspects of CABG.
Both American and European guidelines recommend the use
of the STS risk score,, and the Synergy Between Percutaneous
Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX)
score in an assessment of patient complexity. e SYNTAX score
has been shown to be signicantly associated with clinical outcomes aer PCI and the guidelines include specic recommendations for specic anatomical subgroups of patients expressed by
Guidelinedevelopment
low, intermediate, and high SYNTAX scores. Recommendations
for the type of revascularization are provided based on improving
both long- term clinical outcomes and symptoms. Interestingly,
Despite the publication of separate documents issued by two groups
of authors, the 2011 ACC/ AHA Guidelines have adopted a more
collaborative approach aer the 2004 guidelines. It is worth emphasizing that the 2011 ACC/ AHA Guidelines were written in a joint effort by the PCI and CABG committees and issued recommendations
for revascularization that were harmonized between the two publications. Both the European and the American guidelines have used a
similar methodology for reporting treatment recommendations, including classes of recommendation and levels of evidence. e class
the 2011 ACC/ AHA Guidelines divide their recommendations
regarding the type of revascularization into those which are intended to improve symptoms and those directed to improve longterm survival, while the 2018 ESC/ EACTS Guidelines estimate an
overall treatment ecacy and present a single set of recommendations. is substantial dierence may have a signicant impact
on the nal treatment recommendations, and these discrepancies
require further clarication and consensus among American and
European societies.
designation is used to indicate whether therapy is recommended or
not and the certainty surrounding eect estimates, while the level
of evidence indicates the strength of the data associated with that
recommendation. e only distinction is the wording of classIIa of
Procedural aspects ofcoronary artery
bypassgrafting
the recommendations. While the ACC/ AHA methodology states
that ‘it is reasonable to perform or can be useful/ eective/ benecial’, the ESC/ EACTS methodology oers more uniform wording,
such as ‘it should be considered’. e documents are approved by
the governing bodies of the ACC, the AHA, the AATS, the STS, and
the Society of Cardiovascular Anesthesiologists (SCA) or the ESC
and the EACTS respectively; they represent the ocial policy of the
participating societies.
e 2018 ESC/ EACTS Guidelines list several important procedural recommendations for CABG based on current evidence. e
guidelines recommend complete myocardial revascularization
and minimal aortic manipulation. Routine intraoperative gra
ow measurement should be considered. Arterial graing with internal thoracic (mammary) artery to the le anterior descending
artery system is recommended for all patients. Skeletonization is
recommended for internal thoracic artery harvesting, especially in
Decision- making and patientinformation
patients at higher risk of sternal wound complications. An additional arterial gra should be considered in appropriate patients,
and the use of the radial artery is recommended over the saphe-
Both CABG and PCI have been established as eective methods for
myocardial revascularization., e optimal choice between CABG
and PCI is inuenced by several factors, including patient characteristics, additional comorbidities, clinical presentation, cardiac
function, and the anatomical complexity of the coronary disease.
Additionally, information concerning the long- term ecacy of both
procedures and patient preferences continue to be of utmost importance in treatment decision- making.
Since the 2010 ESC/ EACTS Guidelines and the 2011 ACC/ AHA
Guidelines, the cornerstone for decision- making is the formation
of the Heart Team, dened as a multidisciplinary team consisting
of a clinical/ non- invasive cardiologist, interventional cardiologist,
nous vein in patients with high- grade coronary artery stenosis.
Bilateral internal thoracic artery graing should be considered in
patients who do not have a high risk of sternal wound infection.
For vein harvesting, the endoscopic technique, if performed by experienced surgeons, should be considered to reduce the incidence
of wound complications. If an open technique is planned, the ‘notouch’ technique is preferable. O- pump CABG and no- touch
techniques on the ascending aorta by experienced operators are
recommended in patients with signicant atherosclerotic disease
and high risk. Minimally invasive coronary surgery should be considered in patients with isolated le anterior descending lesions or
the context of hybrid revascularization.
12 Differences and similarities betweenAmerican and European myocardial revascularizationguidelines 117
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Left mainstenosis
While CABG remains the standard of care among class IA recommendations, advances in stenting technology and procedural
which are generally consistent among all guidelines published in the
last decade predict that the majority of patients with three- vessel
disease will continue to be treated with CABG surgery for the foreseeable future.
techniques are introducing PCI as a potential alternative treatment in select patients with le main disease. A subgroup analysis of patients with the SYNTAX score of less than 33 from the
SYNTAX trial set the stage for the Nordic– Baltic– British Le Main
Revascularisation Study (NOBLE) and the Evaluation of XIENCE
versus Coronary Artery Bypass Surgery for Eectiveness of Le
Main Revascularization (EXCEL) trials, which compare CABG
to PCI with newer- generation drug- eluting stents. Given the conicting data and incomplete long- term follow- up of EXCEL and
NOBLE, the task force members decided to adopt a cautious stance
and maintain the recommendations from the 2014 guidelines. In the
2018 ESC/ EACTS Guidelines, the SYNTAX score is also used as a
tool to stratify recommendations for the type of revascularization
among patients with le main disease. PCI holds IA, IIaA, and IIIB
Diabetes
A substantial body of evidence suggests that diabetes is a critical determinant of long- term outcomes aer myocardial revascularization.
Both current guidelines strongly recommend CABG over PCI (IA)
in patients with multivessel disease and who are clinically and angiographically suitable for both treatments. In the European guidelines,
PCI may be considered an acceptable alternative to CABG surgery
only in the select group of patients with relatively non- complex
coronary anatomy expressed by the SYNTAX score of less than 22,
while PCI in patients with a moderate to high SYNTAX score remains contraindicated.
recommendations for patients with SYNTAX scores of less than 23,
23– 32, and greater than 32, respectively. On the other hand, in the
2011 ACC/ AHA CABG Guidelines, PCI has a IIaB recommendation
Graftselection
if the SYNTAX score is lower than 23, and le main stenosis is ostial
or in the main trunk and the STS risk score is greater than 5%. If an
estimated SYNTAX score is intermediate (23– 32), le main stenosis
involves bifurcation and the STS risk score is greater than 2%, then
PCI assumes a IIbB recommendation; however, among patients with
le main disease and high anatomical complexity (SYNTAX score of
>33), PCI cannot be endorsed, as reected by the classIIIB recommendation of both societies.
In line with the 2016 STS Guidelines on arterial conduits, the
European guidelines recommend (IB) the use of arterial graing with
the internal thoracic artery to the anterior descending artery system
as the gold standard for CABG. Furthermore, both guidelines recommend that the use of a second arterial gra should be considered
in virtually all patients less than 70years of age, accounting for the
risk factors of sternal wound complications, the degree of target
vessel stenosis, and the quality of the available gra conduits. e
Multivesseldisease
use of the radial artery is recommended by both guidelines (classIB
in the European guidelines) when graing coronary vessels with a
severe degree of stenosis. Bilateral internal thoracic artery (BITA)
The recommendations for either CABG or PCI in patients with
multivessel (two- or three- vessel) disease is determined by
many factors, such as the number of vessels involved, the anatomical complexity of the lesions (assessed by the SYNTAX
score), presence of proximal left anterior descending stenosis,
and additional comorbidities such as diabetes. The 2018 ESC/
EACTS Guidelines recommend (classIA) PCI for patients with
two- vessel disease, irrespective of proximal anterior descending
artery involvements. Contrarily, the 2011 ACC/ AHA CABG
Guidelines consider PCI to be of uncertain benefit (IIbB) concerning long- term survival, but PCI is indicated (IA) to improve
symptoms. The ACC/ AHA recommendations are based on current safety concerns that include an increase of post- PCI complications, including stent thrombosis and in- stent restenosis.
However, PCI- related short- term and mid- term outcomes may
be significantly improved in the current era due to advances in
stent technologies and antiplatelet therapy.
According to the 2018 ESC/ EACTS Guidelines, CABG holds a
classIA recommendation for the treatment of patients with threevessel disease, whereas PCI should be considered only in selected
patients with relatively non- complex coronary anatomy (SYNTAX
score of <23). Similarly, the 2011 ACC/ AHA CABG Guidelines give
a classIB recommendation to CABG and a classIIbB to PCI if the
SYNTAX score is moderate to high (>22). e recommendations,
graing should be considered (IIaB) in patients who do not have an
increased risk of sternal complications. According to the European
guidelines, ‘no- touch’ vein harvesting should be considered when
an open technique is used to further improve the saphenous vein
gras patency.
e Arterial Revascularisation Trial (ART) was designed to
answer the question of whether BITA graing can improve 10year survival when compared with single internal thoracic artery
(SITA) graing. e nal intention- to- treat analysis shows no
signicant dierences between the two groups in the rates of 10year survival and major adverse events. Important limitations of
the ART include a 14% rate of crossover from the BITA group to
the SITA group, and a considerable proportion (23%) of patients
randomized to the SITA group who also received a radial artery
gra. Indeed, this may dilute the benets among the BITA randomized patients, and made the trial results dicult to interpret
(a fuller analysis of the ART is presented in Chapter34). Based on
the lessons learnt from these previous clinical studies, the ongoing
‘Randomized comparison of the clinical Outcome of single versus
Multiple Arterial gras’ (ROMA) trial aims to compare the use of
two or more arterial gras with the use of single arterial gra for
the primary composite of death, stroke, post- discharge myocardial
infarction, or repeat revascularization among 4300 patients. e
ndings from the ROMA trial should provide a denitive answer
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