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Coronary Artery Bypass Surgery

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Comprehensive Cardiovascular Medicine in the Primary Care Setting

Part of the book series: Contemporary Cardiology ((CONCARD))

Abstract

Coronary artery bypass grafting (CABG) is one of the most common cardiac surgery procedures performed in the United States to treat coronary artery disease (CAD) and has evolved since its introduction in the 1960s (1).

Key Points

• The primary care physician plays a very important role in providing the patient with treatment options and helping the patient make decisions regarding treatment based on the relative risks and interventions.

• The selection of the specific management strategy must incorporate the extent of the patient’s coronary artery disease, co-morbidities, expected symptomatic relief, and survival benefits that have been established and quantitated by clinical trials.

• Current treatment options for coronary artery disease include medical management, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG).

• Several landmark studies performed at the Cleveland Clinic and other institutions from 1985 to 1996 have revealed the left internal mammary (LIMA) to left anterior descending (LAD) artery graft to result in excellent patency rates and outcomes after CABG, and this technique has led to major advances in CABG surgery.

• Trials comparing the outcomes of medical therapy with CABG have shown that in patients with multivessel disease, left ventricular (LV) dysfunction (LVEF less than 50%), and moderate-to-severe angina/ischemia, the survival benefits of CABG clearly exceed the benefits of medical therapy.

• Trials comparing the outcomes of medical therapy with PCI have shown that in patients with stable angina, PCI showed no benefit over medical management in terms of survival, MI, or freedom from subsequent revascularization and that all patients with stable angina should have a trial of optimized medical therapy prior to consideration of PCI.

• Trials comparing CABG to PCI and medical therapy consistently demonstrated that patients with proximal multivessel disease, diabetes mellitus, left main artery disease, left main artery equivalent disease (referring to combined proximal left anterior descending artery disease and proximal left circumflex artery disease), and LV dysfunction have better outcomes with CABG.

• The dominant theme demonstrating the superiority of CABG over medical management and PCI in the context of event-free survival, freedom from major adverse cardiac and cerebrovascular events (MACCE), and lower rates of repeat revascularization occurs in patients with left main disease, left main equivalent disease, multivessel disease, proximal vessel disease, diabetes, and LV dysfunction.

• It is important that a multidisciplinary approach be used to optimally tailor treatment options for the patient with CAD, and the primary care provider is in the unique position to advocate for the patient’s best treatment option from an unbiased perspective.

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Authors and Affiliations

  1. Vanderbilt Heart and Vascular Institute, Nashville, TN, USA

    Ramanan Umakanthan MD, Nataliya V. Solenkova MD, Marzia Leacche MD, John G. Byrne MD & Rashid M. Ahmad MD

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  1. Ramanan Umakanthan MD
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  2. Nataliya V. Solenkova MD
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  1. Sterling Rock Falls Clinic, 101 E. Miller Road, Sterling, 61081, USA

    Peter P. Toth

  2. Brigham & Women's Hospital, Cardiovascular Division, Harvard Medical School, Longwood Ave. 350, Boston, 02115, USA

    Christopher P. Cannon

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Umakanthan, R., Solenkova, N.V., Leacche, M., Byrne, J.G., Ahmad, R.M. (2011). Coronary Artery Bypass Surgery. In: Toth, P., Cannon, C. (eds) Comprehensive Cardiovascular Medicine in the Primary Care Setting. Contemporary Cardiology. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-60327-963-5_13

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