AHA Guidelines - Coronary Artery Revasc 2021

Question 1

significant L main disease preferred approach for revascularization

Answer 1

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

Question 2

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

Answer 2

surgical - improves survival; PCI survival benefit is uncertain

Question 3

radial artery vs saphenous vein for CAD revasc second target?

Answer 3

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

Question 4

best access for PCI for ACS or stable IHD?

Answer 4

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 5

antiplatelets after PCI w/ stable IHD?

Answer 5

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

Question 6

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

Answer 6

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 7

Triple vessel CAD and DM - preferred revasc?

Answer 7

surgical; PCI if poor candidate

Question 8

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

Answer 8

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

Question 9

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?

Answer 9

FFR >0.8 or iFR >0.89 shows NO benefit from PCI

Question 10

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

Answer 10

IVUS

Question 11

STEMI and ischemic symptoms decision making?

Answer 11

WHEN did symptoms happen: < or > 12 hrs?
<12 hrs - PCI feasible? Proceed.
<12 hrs - PCI not feasible & LARGE AREA AT RISK? CABG
>12 hrs - <24 hrs? PCI (2a)
>24 hrs w/ total occlusion w/o sx or severe ischemia - NO PCI

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 12

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

Answer 12

elective - reduce risk of cardiac events

Question 13

Management for NSTE-ACS?

Answer 13

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

Shouldn’t DC these pts.

Question 14

Revasc algorithm in pts w/ SIHD?

Answer 14

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 15

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

Answer 15

SYNTAX 33

Question 16

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

Answer 16

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

Question 17

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

Answer 17

CABG

Question 18

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 18

Do NOT recommend routine coronary revascularization - no benefit.

Question 19

ISCHEMIA-CKD randomized trial result?

Answer 19

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 20

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

Answer 20

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

Question 21

Should you perform routine revascularization for CAD?

Answer 21

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

Question 22

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

Answer 22

PCI is reasonable

Question 23

For PCI, compare DES to BMS?

Answer 23

DES to prevent restenosis, MI or acute stent thrombosis

Question 24

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

Answer 24

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 25

Recommendations of tx for pts w/ stent restenosis?

Answer 25

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

Question 26

Recommendations for antiplatelet therapy peri-PCI?

Answer 26

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 27

Periop analgesia to reduce opioid use in cardiac surgery?

Answer 27

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

Question 28

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

Answer 28

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

Question 29

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

Answer 29

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

Question 30

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

Answer 30

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

Question 31

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

Answer 31

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

Question 32

Can radial artery be used after transradial cath?

Answer 32

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

Question 33

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

Answer 33

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

Question 34

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

Answer 34

oral ca-channel blocker

Question 35

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

Answer 35

endoscopic

Question 36

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

Answer 36

skeletonized

Question 37

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

Answer 37

Nasal swab testing for S aureus
Mupirocin 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 38

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

Answer 38

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 39

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

Answer 39

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

Question 40

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

Answer 40

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

Question 41

What is the glucose goal in intraop CABG pts?

Answer 41

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

Question 42

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

Answer 42

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 43

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

Answer 43

No. No benefit 24 hrs before surgery.

Question 44

Can preop amiodarone help CABG pts?

Answer 44

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 45

When should ASA be started after CABG?

Answer 45

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

Question 46

Should postop beta blockers be used in CABG?

Answer 46

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 47

A-fib after CABG risk and complications?

Answer 47

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

Question 48

Benefit for postop CABG cardiac rehab?

Answer 48

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 49

Role for psychological treatment in coronary revascularization?

Answer 49

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

Question 50

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

Answer 50

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

Question 51

What score should be calculated before every CABG?

Answer 51

STS risk score. COR1 recommendation by AHA.

Question 52

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

Answer 52

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

Question 53

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 53

CABG. COR1.
STICH trial - ICM and LVEF <35 randomized to CABF vs optimal med therapy. CABG resulted in lower 10-year risk of all0cause mortality.