AHA Guidelines - Coronary Artery Revasc 2021 Flashcards
significant L main disease preferred approach for revascularization
surgical - improves survival; PCI still better than med therapy in low/med complexity and LM equally suitable
in pt w/ stable IHD, nl EF, and 3v CAD, what is preferred revasc?
surgical - improves survival; PCI survival benefit is uncertain
radial artery vs saphenous vein for CAD revasc second target?
radial - superior patency, reduced cardiac events, improved survival;
make sure you know if and which radial was accessed during cath
best access for PCI for ACS or stable IHD?
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
antiplatelets after PCI w/ stable IHD?
short duration of dual antiplatelet - reduces bleeding events; after 1-3 mo, transition to plavix monotherapy
Pt presents w/ STEMI s/p PCI for culprit artery. What to do for nonculprit artery intervention?
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.
Triple vessel CAD and DM - preferred revasc?
surgical; PCI if poor candidate
What scoring system is best used for tx decisions for surgical revasc of CAD?
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.
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?
FFR >0.8 or iFR >0.89 shows NO benefit from PCI
In pt w/ intermediate stenosis of LM artery, what can be used to help define lesion severity?
IVUS
STEMI and ischemic symptoms decision making?
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.
STEMI pt s/p PCI of infarct artery. Timing of CABG for complex multivessel non-infarct disease?
elective - reduce risk of cardiac events
Management for NSTE-ACS?
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.
Revasc algorithm in pts w/ SIHD?
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)
What SYNTAX score seems to confer CABG survival benefit over PCI for multivessel CAD?
SYNTAX 33
Pt w/ previous CABG with OPEN LIMA to LAD needs repeat coronary revascularization. What approach is recommended (2a)?
percutaneous - open LIMA to LAD increases risk of redo sternotomy; PCI has lower stroke and mortality rate
Pt w/ multivessel CAD is amenable to either PCI or CABG, but cannot take DAPT (access, tolerance, adherence, etc). What do you do?
CABG
A patient w/ CAD is undergoing NON-cardiac surgery. They do not have LM disease, and CAD is not complex. What do you offer?
Do NOT recommend routine coronary revascularization - no benefit.
ISCHEMIA-CKD randomized trial result?
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.
Pt presents w/ VF/VT or cardiac arrest d/t CAD. What should be done?
Revascularization.
In pt CAD and SCAR-RELATED sustained monomorphic VT, there is NO benefit from revascularization as the sole purpose of preventing recurrent VT
Should you perform routine revascularization for CAD?
No.
It SHOULD be considered in pts w/ instability or ongoing ischemia AFTER conservative therapy.
What should revasc stretegy be for cardiac allograft (txp) vasculopathy and severe, proximal, discrete coronary lesions?
PCI is reasonable
For PCI, compare DES to BMS?
DES to prevent restenosis, MI or acute stent thrombosis
In pt w/ chronic occlusion (CTO) of SVG, should PCI of SVG be done? Should it ever be done?
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.
Recommendations of tx for pts w/ stent restenosis?
ISR w/ planned PCI - use DES (better outcomes, pt needs DAPT)
Diffuse ISR, symptoms, recurrent, indication for revasc - CABG (reduce recurrent events).
Recommendations for antiplatelet therapy peri-PCI?
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.
Periop analgesia to reduce opioid use in cardiac surgery?
Tylenol, ketamine, and precedex.
Regional blocks (truncal nerve)
What mechanical vent strategy should be used for CABG to improve pulmonary mechanics and reduce postop pulm complications?
Intraop lung-protective strategy - TV 6-8 ml/kg predicted BW + PEEP
In low-risk surgery, should PA catheters be recommended?
It is discouraged in low-risk or clinically stable pts - increased interventions and greater health care expense w/o improved MM rates.
What intraop monitoring can help guide anesthetic decision-making and prevent neurocognitive dysfunction (such as in arch cases)?
Cerebral O2 sat (near infrared spectroscopy) to detect cerebral hypoperfusion
How do you choose the arm for radial artery graft harvest?
Use arm w/ best ulnar arterial compensation. If equal, use non-dominant hand.
Can radial artery be used after transradial cath?
should be avoided; BL perc or surgical radial artery procedures should be avoided in pts w/ CAD
What chronic disease process should prompt the CABG surgeon to avoid radial artery graft harvesting?
CKD w/ high likelihood of progression to HD (need it for fistula)
What medicine should be added in the first postop year after CABG if radial artery graft is used?
oral ca-channel blocker
What technique can reduce risk of wound complications in SVG harvest?
endoscopic
What technique can reduce risk of wound complications in IMA harvest?
skeletonized
Best practice to reduce sternal wound infection in pts undergoing CABG?
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
What level of CAD may be beneficial to revascularize if undergoing cardiac operations for other heart disease?
intermediate (2b) - 40-70% stenosis (as opposed to 70% non-LM and 50% LM); may reduce ischemic events; may benefit from FFR or iFR
What intraop study is the gold standard for detection of aortic atherosclerosis and may reduce incidence of atheroembolic complications (eg stroke) in CABG?
epiaortic US (better than TEE and palpation) - low time, risk, and monetary cost
In terms of CPB, what technique can be used to decrease the risk of perioperative stroke in pt w/ significant aortic calcification?
off-pump CAB - avoids aortic manipulation (2a); may also be beneficial for pts w/ significant pulm disease (2b)
What is the glucose goal in intraop CABG pts?
<180. Use an insulin infusion. Same as postop goal.
Decreases sternal wound infection rate.
A pt undergoing CABG asks if they need to stop ASA preop? What about other antiplatelets?
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.
In pts undergoing elective CABG not already on ASA, should it be started immediately preop?
No. No benefit 24 hrs before surgery.
Can preop amiodarone help CABG pts?
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.
When should ASA be started after CABG?
within 6 hrs postop;
of note, select pts may benefit from DAPT if vein grafts are in bad targets
Should postop beta blockers be used in CABG?
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.
A-fib after CABG risk and complications?
18% rate after CABG. 4x inc stroke risk. 3x inc all mortality.
Benefit for postop CABG cardiac rehab?
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.
Role for psychological treatment in coronary revascularization?
COR 1 recommendation to treat depression, anxiety, or stress w/ CBT, counseling, or medicine to improve QoL and outcomes.
What is recommended to maximize smoking cessation and reduce adverse cardiac events in tobacco users after coronary revascularization?
combo behavioral and pharm therapy; start during hospitalization and f/u 1 mo after DC to facilitate; reduces M&M
What score should be calculated before every CABG?
STS risk score. COR1 recommendation by AHA.
What major pathologies are not calculated in the STS risk score? How else are they evaluated?
Cirrhosis - MELD.
Frailty - gait speed.
Malnutrition - MUST.
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?
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.
