Surgical revascularisation of the acute coronary artery syndrome

Abstract

Although the European Society of Cardiology and American Heart Association/American College of Cardiology guidelines provide some suggestions regarding coronary artery bypass grafting (CABG) in the acute coronary syndrome (ACS), the exact indications for surgery in this diverse spectrum of disease requires further clarification. ACS may present with different scenarios, from NSTEMI to cardiogenic shock. Primary percutaneous coronary intervention is the first-line treatment in most cases; however, there may be a subgroup of ACS patients in whom CABG may be preferred over percutaneous coronary intervention, particularly in the setting of triple vessel disease. CABG can be performed with reasonably low mortality and excellent outcome, particularly in the case of NSTEMI. Furthermore, off-pump or on-pump beating heart techniques may further improve the feasibility and outcomes of CABG. Where possible every patient should be immediately referred to a tertiary centre and evaluated by the ‘heart team’. Here risk stratification and intervention according to the expert consensus may be rapidly implemented in order to improve both morbidity and mortality.

Keywords::

• acute coronary syndrome
• cardiogenic shock
• coronary artery bypass grafting
• NSTEMI
• STEMI
• surgical indications

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Acute coronary syndrome (ACS) is a heterogeneous spectrum of disease from non ST-elevation myocardial infarction (NSTEMI) to cardiogenic shock.

• More than two-thirds of patients with ACS present with triple-vessel disease.

• Percutaneous coronary intervention (PCI) is the first-line therapy in these patients in order to acutely reperfuse myocardium supplied by the target vessel. However, there are no prospective randomized trials comparing PCI and coronary artery bypass grafting (CABG) in ACS.

• Assessing the level of risk is of a paramount importance, and intervention should be carried out in NSTEMI patients with a global registry of acute coronary events score >140.

• Delaying revascularization in NSTEMI may increase mortality.

• CABG during the same hospitalization may be the appropriate choice in stable NSTEMI patients with a high global registry of acute coronary events score.

• In case of STEMI, PCI remains the first-line treatment. CABG is indicated in the case of PCI failure, where the culprit lesion is unsuitable for PCI (like left mainstream) or there are refractory symptoms.

• Cardiogenic shock carries a high mortality. Pre-operative intra-aortic balloon pump may lower the mortality rate at 1 year.

• Off-pump or on-pump beating heart surgery may improve outcomes in high-risk patients.

• The use of the new antiplatelet drugs as prasugrel and ticagrelor should not be a contraindication for CABG.

• CABG may give rise to a higher rate of post-operative stroke compared to PCI. Dual antiplatelet therapy for 12 months after discharge may lower this incidence of stroke and improve graft patency.