© 2004 by the American College of Cardiology Foundation and the American Heart Association, Inc. ACC/AHA PRACTICE GUIDELINES—FULL TEXT ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Developed in Collaboration With the American Association for Thoracic Surgery and the Society of Thoracic Surgeons WRITING COMMITTEE MEMBERS Kim A. Eagle, MD, FACC, FAHA, Co-chair Robert A. Guyton, MD, FACC, FAHA, Co-chair Ravin Davidoff, MB, BCh, FACC, FAHA L. David Hillis, MD, FACC Fred H. Edwards, MD, FACC, FAHA Adolph M. Hutter, Jr., MD, MACC, FAHA Gordon A. Ewy, MD, FACC, FAHA Bruce Whitney Lytle, MD, FACC Timothy J. Gardner, MD, FACC, FAHA Robert A. Marlow, MD, MA, FAAFP James C. Hart, MD, FACC William C. Nugent, MD Howard C. Herrmann, MD, FACC, FAHA Thomas A. Orszulak, MD, FACC TASK FORCE MEMBERS Elliott M. Antman, MD, FACC, FAHA, Chair Sidney C. Smith, Jr., MD, FACC, FAHA, Vice Chair Joseph S. Alpert, MD, FACC, FAHA† Gabriel Gregoratos, MD, FACC, FAHA† Jeffrey L. Anderson, MD, FACC, FAHA Jonathan L. Halperin, MD, FACC, FAHA David P. Faxon, MD, FACC, FAHA Loren F. Hiratzka, MD, FACC, FAHA Valentin Fuster, MD, PhD FACC, FAHA Sharon Ann Hunt, MD, FACC, FAHA Raymond J. Gibbons, MD, FACC, FAHA†‡ Alice K. Jacobs, MD, FACC, FAHA Joseph P. Ornato, MD, FACC, FAHA †Former Task Force Member (specify version and reprint number): Up to 999 copies, call 1-800-611-6083 ‡Immediate Past Chair (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1789, fax 214-691-6342, or e-mail [email protected]. This document was approved by the American College of Cardiology Permissions: Multiple copies, modification, alteration, enhancement, and/or Foundation Board of Trustees in March 2004 and by the American Heart distribution of this document are not permitted without the express permission Association Science Advisory and Coordinating Committee in June 2004. of the American College of Cardiology Foundation. Please direct requests to When citing this document, the American College of Cardiology Foundation [email protected]. requests that the following citation format be used: Eagle KA, Guyton RA, doi:10.1016/j.jacc.2004.08.002 Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis LD, Hutter AM Jr, Lytle BW, Marlow RA, Nugent WC, Orszulak TA. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a TABLE OF CONTENTS report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines 1. PREAMBLE and INTRODUCTION............................ .e214 for Coronary Artery Bypass Graft Surgery). American College of Cardiology 1.1. Preamble.................................................................. e214 Web Site. Available at: http://www.acc.org/clinical/guidelines/cabg/cabg.pdf. 1.2. Introduction..............................................................e215 Copies: This document is available on the World Wide Web sites of the 2. GENERAL CONSIDERATIONS AND American College of Cardiology (www.acc.org) and the American Heart BACKGROUND.............................................................e216 Association (www.my.americanheart.org). Single copies of this document are 3. OUTCOMES....................................................................e218 6 available by calling 1-800-253-4636 or writing the American College of Cardiology Foundation, Resource Center, at 9111 Old Georgetown Road, 3.1. Hospital Outcomes...................................................e218 Bethesda, MD 20814-1699. Ask for reprint number 71-0280. To obtain a reprint 3.1.1. Introduction....................................................e218 of the Summary Article published in the September 1, 2004, issue of the 3.1.2. Predicting Hospital Mortality.........................e218 Journal of the American College of Cardiology and the August 31, 2004, issue 3.1.3. Morbidity Associated With CABG: Adverse of Circulation, ask for reprint number 71-0281. To purchase bulk reprints Cerebral Outcomes.........................................e220 Eagle and Guyton et al. 2004 ACC - www.acc.org e214 ACC/AHA Practice Guidelines AHA - www.americanheart.org 3.1.4. Morbidity Associated With CABG: 4.1.6. Strategies to Reduce Perioperative Bleeding Mediastinitis...................................................e223 and Transfusion..............................................e252 3.1.5. Morbidity Associated With CABG: Renal 4.1.7. General Management Considerations............e254 Dysfunction....................................................e223 4.2. Maximizing Postoperative Benefit...........................e254 3.1.6. Posthospital Outcomes...................................e225 4.2.1. Antiplatelet Therapy for SVG Patency..........e254 3.2. Comparison of Medical Therapies Versus Surgical 4.2.2. Pharmacological Management of Revascularization......................................................e225 Hyperlipidemia...............................................e254 3.2.1. Overview........................................................e226 4.2.3. Hormonal Manipulation.................................e255 3.2.2. Location and Severity of Stenoses.................e228 4.2.4. Smoking Cessation.........................................e255 3.2.2.1. Left Main Disease.............................e228 4.2.5. Cardiac Rehabilitation....................................e256 3.2.2.2. Three-Vessel Disease........................ e228 4.2.6. Emotional Dysfunction and Psychosocial 3.2.2.3. Proximal LAD Disease..................... e229 Considerations................................................e257 3.2.2.4. LV Function.......................................e229 4.2.7. Rapid Sustained Recovery After Operation...e257 3.2.2.5. Symptoms/Quality of Life............... .e230 4.2.8. Communication Between Caregivers.............e257 3.2.2.6. Loss of Benefit of Surgery............... e231 5. SPECIAL PATIENT SUBSETS......................................e257 3.2.2.7. Summary........................................... e231 5.1. CABG in the Elderly: Age 70 and Older..................e257 3.3. Comparison with Percutaneous Techniques.............e232 5.2. CABG in Women......................................................e260 3.3.1. Overview of Randomized Trials....................e232 5.3. CABG in Patients With Diabetes.............................e261 3.3.2. Results of Randomized Trials........................e234 5.4. CABG in Patients With Pulmonary Disease, COPD, 3.3.2.1. Acute Outcome..................................e234 or Respiratory Insufficiency.....................................e261 3.3.2.2. Long-Term Outcome.........................e234 5.5. CABG in Patients With End-Stage Renal Disease.. e263 3.3.2.3. Special Subsets..................................e236 5.6. Valve Disease........................................................... e263 3.3.2.4. Results from Nonrandomized Trials 5.7. Reoperation.............................................................. e264 and Registries....................................e237 5.8. Concomitant PVD....................................................e265 3.3.2.5. Conclusions.......................................e237 5.9. Poor LV Function.....................................................e266 4. MANAGEMENT STRATEGIES....................................e237 5.10. Transplantation Patients......................................... e266 4.1. Reduction of Perioperative Mortality and Morbidity e237 5.11. CABG in Acute Coronary Syndromes...................e267 4.1.1. Reducing the Risk of Brain Dysfunction After 6. IMPACT OF EVOLVING TECHNOLOGY...................e268 Coronary Bypass............................................e239 6.1. Less-Invasive CABG................................................e268 4.1.1.1. Type 1 Neurological Injury...............e239 6.1.1. Robotics.........................................................e270 4.1.1.1.1. Aortic Atherosclerosis and 6.2. Arterial and Alternate Conduits............................... e270 Macroembolic Stroke........ e239 6.3. Percutaneous Technology.........................................e272 4.1.1.1.2. Atrial Fibrillation and 6.4. Transmyocardial Revascularization.........................e273 Postoperative Stroke.......... e241 4.1.1.1.3. Recent Anterior MI, LV Mural 7. INSTITUTIONAL AND OPERATOR COMPETENCE. e274 Thrombus, and Stroke Risk. e242. 7.1. Volume Considerations.............................................e274 4.1.1.1.4. Recent Antecedent 7.2. Report Cards and Quality Improvement..................e275 Cerebrovascular Accident...e242 7.3. Hospital Environment..............................................e276 4.1.1.1.5. CPB Time and Neurological 8. ECONOMIC ISSUES.....................................................e277 Risk.....................................e242 8.1. Cost-Effectiveness of CABG................................... e277 4.1.1.1.6. Carotid Disease and Neuro- 8.2. Cost Comparison With Angioplasty.........................e277 logical Risk Reduction.......e242 8.3. Cost Reduction in Coronary Bypass........................e278 4.1.1.2. Type 2 Neurological Injury...............e245 4.1.1.2.1. Reducing the Risk of 9. INDICATIONS................................................................e279 Microembolization.............e245 9.1. Introduction..............................................................e279