AHA Guidelines - Coronary Artery Revasc 2021

Question 1

In patients being considered for CABG, calculation of what should be done to stratify patient risk?

Answer 1

STS risk score

Question 2

significant L main disease preferred approach for revascularization

Answer 2

surgical - improves survival; PCI still better than med therapy in low/med complexity and LM equally suitable

Question 3

in pt w/ stable IHD, nl EF, and 3v CAD, what is preferred revasc?

Answer 3

surgical - improves survival; PCI survival benefit is uncertain

Question 4

radial artery vs saphenous vein for CAD revasc second target?

Answer 4

radial - superior patency, reduced cardiac events, improved survival;
make sure you know if and which radial was accessed during cath

Question 5

best access for PCI for ACS or stable IHD?

Answer 5

radial better than femoral - dec bleeding and vasc complications, ACS w/ radial approach also has reduced mortality;

if doing CABG after cath and are planning radial conduit, make sure you know which arm was accessed

Question 6

Dual or single antiplatelets after PCI w/ stable IHD?
Length of time and reasoning?

Answer 6

short duration of dual antiplatelet - reduces bleeding events; after 1-3 mo, transition to plavix monotherapy

Question 7

Pt presents w/ STEMI s/p PCI for culprit artery. What to do for nonculprit artery intervention?

Answer 7

Staged perc intervention (while inpt or after DC) for nonculprit - improved outcomes; can be done at initial PCI, but benefit unclear - do if low-complexity and no renal disease.

PCI of nonculprit in cardiogenic shock can be harmful.

Question 8

Triple vessel CAD and DM - preferred revasc?

Answer 8

surgical; PCI if poor candidate

Question 9

What scoring system is best used for tx decisions for surgical revasc of CAD?

Answer 9

STS surgical risk score. (COR1)
SYNTAX score benefit is less clear d/t interobserver variability - more useful for demonstration of complexity for PCI vs CABG decision. (2b)

Question 10

What procedural measurement can help decision making to proceed w/ PCI in pt w/ angina or equivalent when it isn’t otherwise clear from cath (angiographically intermediate)?

Answer 10

FFR >0.8 or iFR >0.89 - no benefit for revasc.
Deferring PCI assd w/ lower rates of major adverse cardiovascular event (MACE).
Of note, FFR does not seem to help improve SURGICAL outcomes.

Question 11

In pt w/ intermediate stenosis of LM artery, what can be used to help define lesion severity?

Answer 11

IVUS (2a)

Question 12

STEMI and PCI not feasible. Cardiogenic shock and/or instability despite IABP. What should be done?

Answer 12

CABG. Irrespective of time delay from MI onset (24 hrs is out of window if no ongoing ischemia).
Early revascularization is associated w/ significant survival benefit.
Specifically, the mortality at 6 mo is improved (30-day survival is not when compared to medical mgmt).

Question 13

Pt has STEMI and mechanical complication (VSD, MVR, free wall rupture), should you do CABG at the time of the surgery?

Answer 13

Yes. COR1. Goal is improving survival.
Mechanical support stabilization is often performed, but if ongoing instability or ischemia, surgery may be only option if otherwise a good candidate.

Question 15

Can CABG as a primary revascularization strategy ever be considered for STEMI?

Answer 15

Yes. If PCI is not possible/unsuccessful for anatomic reasons, or even for LM or multivessel CAD. This is particularly effective if there is a large area of myocardium at risk.

Question 16

STEMI pt <12 hrs and PCI not feasible. Large area at risk and ongoing ischemia despite medical therapy and mechanical support. What is revascularization strategy?

Answer 16

Emergent/Urgent CABG (2a).
This is the only indication for EMERGENCY isolated CABG.

Question 17

Fibrinolytic therapy is recommended only in which STEMI cases?

Answer 17

primary PCI is not immediately available and the delay from hospital presentation to PCI is anticipated to be >120 minutes

Question 18

STEMI and ischemic symptoms decision making?

Answer 18

WHEN did symptoms happen: < or > 12 hrs?
<12 hrs - PCI feasible? Proceed.
<12 hrs - PCI not feasible & LARGE AREA AT RISK? CABG (irrespective of time delay)
>12 hrs - <24 hrs? PCI (2a)
>24 hrs w/ total occlusion w/o sx or severe ischemia - NO PCI (delayed PCI after 24 hrs should only be considered in pts w/ patent artery)

ASSOCIATED ISSUES?
>12 hrs - cardiogenic shock or HF? revasc (PCI pref if feasible)
>12 hrs - ongoing ischemia, HF, VF/VT? primary PCI

Failed PCI in STEMI pt w/o ischemia or large area of myocardium; or w/ poor targets - NO emergency CABG.

In conclusion… revasc if <24, shock, ischemia, or unstable rhythm.

Question 19

STEMI pt w/ failed primary PCI. Pt is asymptomatic now, the area of possible ischemia is small, and the distal targets are poor. Cardiology asking about CABG. What is the answer?

Answer 19

CABG could cause harm. CABG has a limited role in the acute phase of STEMI, and its use in this setting continues to decrease.

Question 20

Asymptomatic and stable pt w/ STEMI who presents 24 hrs after initial symptoms (resolved) w/o evidence of severe ischemia. ED calls asking for PCI. What is the answer?

Answer 20

No benefit. PCI should not be performed.

Question 21

HD stable pt w/ STEMI s/p successful primary PCI. Pt has multivessel disease. What should be done for the non-infarct significant stenosis? What is the timing?
Is there anything that could alter this plan?

Answer 21

Usually staged PCI if not complex. (1)
Low-risk w/ low-complexity lesions? -> PCI of non-culprit at same time.
Complex multivessel lesions? -> can consider CABG vs staged PCI (2a) after heart team discussion (1)

Question 22

STEMI pt s/p PCI of infarct artery. Timing of CABG for complex multivessel non-infarct disease?

Answer 22

elective - reduce risk of cardiac events (2a)

Question 23

Management for NSTE-ACS?

Answer 23

Shock? Angina? VF/VT? -> immediate/emergent revasc
GRACE >140? = high risk -> early revasc w/in 24 hrs
Initially stabilized w/ int/low risk of clinical event? - revasc before DC.

Typically, this is done with PCI, but CABG is not inferior.
Shouldn’t DC these pts.

Question 24

Although there are no randomized trials specifically evaluating emergency CABG versus medical therapy or delayed revascularization in patients with NSTE-ACS and failed PCI who have ongoing ischemia or hemodynamic compromise, multiple retrospective reviews have noted what?

Answer 24

Reduced mortality with an emergency approach.
Ie. If a coronary patient fails PCI, and they have ongoing signs of ischemia or hemodynamic compromise, these are patients who require emergency CABG.

If pt is on DAPT, appropriate safe timing of CABG is determined with a heart team. If you go for CABG, this may be a patient that should be left open and packed until bleeding stops.

Question 25

Revasc algorithm in pts w/ SIHD?

Answer 25

Refractory angina (eg requiring lots of nitro)? revasc (CABG best outcomes in intermed f/u)
LM? CABG
Multivessel? CABG (especially if low EF - benefit >10 yrs)

Question 26

In pt w/ SIHD, nl EF, and 1 or 2 vessel CAD not involving LAD, what would you recommend for coronary revascularization?

Answer 26

Not recommended. Does not benefit (3).

Question 27

What SYNTAX score seems to confer CABG survival benefit over PCI for multivessel CAD?

Answer 27

SYNTAX 33

Question 28

Pt w/ previous CABG with OPEN LIMA to LAD needs repeat coronary revascularization. What approach is recommended (2a)?

Answer 28

percutaneous - open LIMA to LAD increases risk of redo sternotomy; PCI has lower stroke and mortality rate

Question 29

Pt w/ multivessel CAD is amenable to either PCI or CABG, but cannot take DAPT (access, tolerance, adherence, etc). What do you do?

Answer 29

CABG

Question 30

A patient w/ CAD is undergoing NON-cardiac surgery. They do not have LM disease, and CAD is not complex. What do you offer?

Answer 30

Do NOT recommend routine coronary revascularization - no benefit.

Question 31

ISCHEMIA-CKD randomized trial result?

Answer 31

Randomized cath revasc +/- GDMT in stable pt w/ moderate CKD vs conservative mgmt.
Initial invasive strategy showed NO benefit over conservative.

IE In asx ptx w/ stable CAD and CKD, routine angio and revasc not needed.

STILL should revasc STEMI and high-risk NSTE-ACS as long as measures are taken to reduce risk of AKI; low-risk NSTE-ACS should have risk/benefit analysis.

Question 32

Pt presents w/ VF/VT or cardiac arrest d/t CAD. What should be done?

Answer 32

Revascularization.
Of note… In pt w/ CAD and SCAR-RELATED sustained monomorphic VT, there is NO benefit from revascularization as the sole purpose of preventing recurrent VT

Question 33

Should you perform routine revascularization for CAD?

Answer 33

No.
It SHOULD be considered in pts w/ instability or ongoing ischemia AFTER conservative therapy.

Question 34

What should revasc stretegy be for cardiac allograft (txp) vasculopathy and severe, proximal, discrete coronary lesions?

Answer 34

PCI is reasonable

Question 35

For PCI, compare DES to BMS?

Answer 35

DES to prevent restenosis, MI or acute stent thrombosis

Question 36

In pt w/ chronic occlusion (CTO) of SVG, should PCI of SVG be done? Should it ever be done?

Answer 36

No. Not for CTO.
PCI of SVG is possible in select pts, should probably use “embolic protection device.” PCI of native artery (over SVG) is also possible in select pts.

Question 37

Recommendations of tx for pts w/ stent restenosis?

Answer 37

ISR w/ planned PCI - use DES (better outcomes, pt needs DAPT)
Diffuse ISR, symptoms, recurrent, indication for revasc - CABG (reduce recurrent events).

Question 38

Recommendations for antiplatelet therapy peri-PCI?

Answer 38

Loading ASA and plavix (for ACS and SIHD, and after fibrinolytic therapy), then daily ASA and plavix.

They should also be anticoagulated during PCI to reduce ischemic events. Bivalrudin may reduce bleeding. Bivalrudin or argatroban for HIT.

Question 39

Periop analgesia to reduce opioid use in cardiac surgery?

Answer 39

Tylenol, ketamine, and precedex.
Regional blocks (truncal nerve).

Question 40

What mechanical vent strategy should be used for CABG to improve pulmonary mechanics and reduce postop pulm complications?

Answer 40

Intraop lung-protective strategy - TV 6-8 ml/kg predicted BW + PEEP

Question 41

In low-risk surgery, should PA catheters be recommended?

Answer 41

It is discouraged in low-risk or clinically stable pts - increased interventions and greater health care expense w/o improved MM rates.

Question 42

What intraop monitoring can help guide anesthetic decision-making and prevent neurocognitive dysfunction (such as in arch cases)?

Answer 42

Cerebral O2 sat (near infrared spectroscopy) to detect cerebral hypoperfusion

Question 43

How do you choose the arm for radial artery graft harvest?

Answer 43

Use arm w/ best ulnar arterial compensation. If equal, use non-dominant hand.

Question 44

Can radial artery be used after transradial cath?

Answer 44

should be avoided; BL perc or surgical radial artery procedures should be avoided in pts w/ CAD

Question 45

What chronic disease process should prompt the CABG surgeon to avoid radial artery graft harvesting?

Answer 45

CKD w/ high likelihood of progression to HD (need it for fistula)

Question 46

What medicine should be added in the first postop year after CABG if radial artery graft is used?

Answer 46

oral ca-channel blocker

Question 47

Best practices for use of bypass conduits in CABG?
10 points.

Answer 47

Objectively assess palmar arch completeness and ulnar compensation before harvesting the radial artery. Use the arm with the best ulnar compensation for radial artery harvest.

Use radial artery grafts to target vessels with subocclusive stenosis.

Avoid radial artery after transradial catheterization.

Avoid the use of the radial artery in patients with chronic kidney disease and a high likelihood of rapid progression to hemodialysis (preserves Cimino option).

Oral calcium channel blockers for first postop year after radial artery grafting.

Avoid bilateral perc or surgical radial artery procedures in patients with CAD to preserve the artery for future use.

Harvest IMA using skeletonized technique - reduce sternal wound complications.

Endoscopic saphenous vein harvest in those at risk of wound complications.

No-touch saphenous harvest technique in patients at low risk of wound complications.

Use skeletonized R gastroepiploic artery to graft R coronary artery target vessels with subocclusive stenosis if the operator is experienced with use of the artery.

Question 48

What technique can reduce risk of wound complications in SVG harvest?

Answer 48

endoscopic

Question 49

What technique can reduce risk of wound complications in IMA harvest?

Answer 49

skeletonized

Question 50

Best practice to reduce sternal wound infection in pts undergoing CABG?

Answer 50

Nasal swab testing for S aureus
Mupirocin 2% ointment if known nasal carrier or unknown status
Redose ppx abx after 2 half-lives or if extensive blood loss
Check A1c
Treat all infx b4 nonemergent CAB
Stop smoking
Apply topical abx to sternal cut edges on opening and before closing
Skeletonize BIMA harvest
Stop ppx abx after 48 hrs

Question 51

What level of CAD may be beneficial to revascularize if undergoing cardiac operations for other heart disease?

Answer 51

intermediate (2b) - 40-70% stenosis (as opposed to 70% non-LM and 50% LM); may reduce ischemic events; may benefit from FFR or iFR

Question 52

What intraop study is the gold standard for detection of aortic atherosclerosis and may reduce incidence of atheroembolic complications (eg stroke) in CABG?

Answer 52

epiaortic US (better than TEE and palpation) - low time, risk, and monetary cost

Question 53

In terms of CPB, what technique can be used to decrease the risk of perioperative stroke in pt w/ significant aortic calcification?

Answer 53

off-pump CAB - avoids aortic manipulation (2a); may also be beneficial for pts w/ significant pulm disease (2b)

Question 54

What is the glucose goal in intraop CABG pts?

Answer 54

<180. Use an insulin infusion. Same as postop goal.
Decreases sternal wound infection rate.

Question 55

A pt undergoing CABG asks if they need to stop ASA preop? What about other antiplatelets?

Answer 55

No. ASA continues until surgery. Same w/ beta-block.
Plavix and ticagrelor should be stopped 24 hrs for URGENT CABG.
Short-acting Gp IIb/IIIa inh should be stopped 4 hrs preop (eptifibatide, tirofiban) to reduce bleeding and transfusion rate.
Abciximab should be stopped 12 hrs to reduce bleeding and transfusion rate.

For elective CABG: stop plavix 5 days, ticagrelor 3 days, parasugrel 7 days.

Question 56

In pts undergoing elective CABG not already on ASA, should it be started immediately preop?

Answer 56

No. No benefit 24 hrs before surgery.

Question 57

Can preop amiodarone help CABG pts?

Answer 57

2a rec to reduce postop afib. Use preop oral amio - risk some bradycardia or episodes of hypotension. May be best to select for pts at high risk for afib.

Question 58

When should ASA be started after CABG?

Answer 58

within 6 hrs postop;
of note, select pts may benefit from DAPT if vein grafts are in bad targets

Initiation of aspirin therapy in the immediate preoperative period (<24 hours) has been investigated in 2 randomized trials. In the first trial,24 patients undergoing CABG who received 100 mg of aspirin 1 to 2 hours before surgery experienced a composite outcome of death and thrombotic complications at 30 days and an incidence of major bleeding and cardiac tamponade that were similar to those seen with placebo.24 In the second trial,25 patients randomized to receive 300 mg of aspirin the night before surgery had increased episodes of major bleeding (>750 mL in 24 hours, or 1000 mL overall) and increased transfusion rates, but no significant differences were found in major cardiovascular events at early (30 days) or long-term (36 months) time points compared with placebo.

Question 59

Should postop beta blockers be used in CABG?

Answer 59

In SIHD w/ nl LVEF, routine chronic beta blockers are NOT beneficial in cardiovascular outcome, HOWEVER, they reduce incidence of atrial fibrillation and should be started ASAP after CABG.

Question 60

A-fib after CABG risk and complications?

Answer 60

18% rate after CABG. 4x inc stroke risk. 3x inc all mortality.

Question 61

Benefit for postop CABG cardiac rehab?

Answer 61

Yes (COR 1). Reduces deaths and hospital readmit. Improves QoL.
Pts should also be educated about CVD and modify risk factors to reduce CV events.

Question 62

Role for psychological treatment in coronary revascularization?

Answer 62

COR 1 recommendation to treat depression, anxiety, or stress w/ CBT, counseling, or medicine to improve QoL and outcomes.

Question 63

What is recommended to maximize smoking cessation and reduce adverse cardiac events in tobacco users after coronary revascularization?

Answer 63

combo behavioral and pharm therapy; start during hospitalization and f/u 1 mo after DC to facilitate; reduces M&M

Question 64

What major pathologies are not calculated in the STS risk score? How else are they evaluated?

Answer 64

Cirrhosis - MELD.
Frailty - gait speed.
Malnutrition - MUST.

Question 65

A patient has SIHD (stable ischemic heart disease) w/ EF <35%. He has mvCAD and is otherwise suitable for CABG. What should the treatment be?

Answer 65

CABG. COR1.
STICH trial - ICM and LVEF <35 randomized to CABF vs optimal med therapy. CABG resulted in lower 10-year risk of all-cause mortality.

Question 66

Manage SCAD (spontaneous coronary artery DISSECTION).

Answer 66

If hemodynamic instability or ongoing ischemia despite conservative therapy, revascularization may be considered (2b).
Routine revascularization should not be performed (3:harm).

Question 67

In patients with chronic occlusion of an SVG (previous CABG), percutaneous revascularization of the SVG should be done?

Answer 67

No. (3: harm)

Question 68

For CABG, what strategy may improve outcomes for patients with increased pulmonary risk?

Answer 68

Off-pump CABG has been shown to be associated with earlier extubation, reduced blood transfusion, and reduced duration of mechanical ventilation compared with on-pump CABG and may improve outcomes for patients with increased pulmonary risk, which is perhaps related to avoidance of the systemic inflammatory response attributable to cardiopulmonary bypass and its impact on pulmonary function.