Chronic stable angina coronary artery bypass grafting indications

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Associate Editor(s)-In-Chief: ; John Fani Srour, M.D.; Smita Kohli, M.D.

Overview
Coronary Artery Bypass Grafting (CABG) is carried out to prolong life or improve its quality.

Indications
Trials conducted in the 1970s offered no signficant evidence that CABG offered mortality benefits compared to medical therapy. However, in recent years, several trials have established the survival benefits in selected patients.

Patients with left main coronary artery stenosis or left main equivalent disease (defined as severe (≥70 percent) proximal left anterior descending and proximal left circumflex disease):

 * The Veterans Administration Cooperative Study compared a strategy of initial CABG versus deferred CABG. Researchers observed a substantial survival advantage in pateints assigned to initial CABG at two years (93 versus 71 percent) and at 11 year, but not at 18 years out. The benefit was greatest in high-risk patients with >75 percent left main stenosis and/or left ventricular dysfunction.


 * The CASS registry demonstrated similar results. In an overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration, researchers found that the relative risk reduction for death provided by CABG over medical therapy alone was greater at five years for left main disease than for three vessel or one or two vessel disease (odds ratio 0.32 versus 0.58 and 0.77); the absolute survival benefit from CABG among those with left main disease was 19.3 months.


 * Researchers have also evaluated the usage of PCI for left main coronary artery stenosis. PCI has been performed in patients with angina and left main disease who are considered inoperable, at high risk for CABG, or with prior CABG and one patent graft to either the left anterior descending or circumflex artery ("protected" left main).

Patients with multivessel coronary disease and left ventricular dysfunction
Reduced left ventricular function is an important determinant of prognosis in patients with stable angina and is an indication for revascularization.
 * CABG may improve survival in patients with left ventricular dysfunction and hibernating myocardium; therefore, myocardial viability should be assessed prior to recommending CABG in patients with multivessel coronary disease and left ventricular dysfunction.
 * CASS registry showed that survival at seven years was improved with CABG compared to medical treatment (88 versus 65 percent) in patients with an LVEF between 35 and 49 percent and had three vessel disease. No benefit from CABG could be identified in patients with one or two vessel disease.

Vote on and Suggest Revisions to the Current Guidelines

 * The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina


 * Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology


 * TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina


 * The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina