Re-evaluating the Role of CABG in Acute Coronary Syndromes
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MANAGEMENT OF ACUTE CORONARY SYNDROMES (H JNEID, SECTION EDITOR)
Re-evaluating the Role of CABG in Acute Coronary Syndromes Douglas Farmer 1,2,3
&
Ernesto Jimenez 1,2,3
# This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2020
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. Keywords Acute coronary syndrome . CABG . Percutaneous interventions
Introduction Coronary artery bypass grafting (CABG) has for decades been the mainstay of myocardial revascularization, including for patients who present with acute coronary syndrome (ACS). With the development of endovascular interventions and the evolution of drug-eluting stents, percutaneous coronary intervention (PCI) has now become the primary mode of revascularization after ACS. ACS includes the clinical entities of unstable angina (UA), non-ST-elevation acute myocardial infarction (NSTEMI), and This article is part of the Topical Collection on Management of Acute Coronary Syndromes * Douglas Farmer [email protected] Ernesto Jimenez [email protected] 1
Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
2
Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
3
Division of Cardiothoracic Surgery, Michael E. DeBakey VA Medical Center, Houston, TX, USA
ST-elevation myocardial infarction (STEMI). Approximately 40% of all patients diagnosed with an ACS have multivessel coronary artery disease (MV-CAD), which is usually better treated with CABG than with multivessel PCI. Most studies comparing PCI to CABG have primarily included patients with stable CAD who underwent elective revascularization, rather than those requiring more urgent revascularization. Thus, the results of those trials have limited applicability to patients presenting with ACS. However, the long-term outcomes of these studies, specifically the less frequent need for repeat revascularization, lower rate of recurrent MI, and survival advantages
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