AHA Guidelines - Coronary Artery Revasc 2021 Flashcards Preview

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Flashcards in AHA Guidelines - Coronary Artery Revasc 2021 Deck (68)
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1
Q

In patients being considered for CABG, calculation of what should be done to stratify patient risk?

A

STS risk score

2
Q

significant L main disease preferred approach for revascularization

A

surgical - improves survival; PCI still better than med therapy in low/med complexity and LM equally suitable

3
Q

in pt w/ stable IHD, nl EF, and 3v CAD, what is preferred revasc?

A

surgical - improves survival; PCI survival benefit is uncertain

4
Q

radial artery vs saphenous vein for CAD revasc second target?

A

radial - superior patency, reduced cardiac events, improved survival;
make sure you know if and which radial was accessed during cath

5
Q

best access for PCI for ACS or stable IHD?

A

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

6
Q

Dual or single antiplatelets after PCI w/ stable IHD?
Length of time and reasoning?

A

short duration of dual antiplatelet - reduces bleeding events; after 1-3 mo, transition to plavix monotherapy

7
Q

Pt presents w/ STEMI s/p PCI for culprit artery. What to do for nonculprit artery intervention?

A

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.

8
Q

Triple vessel CAD and DM - preferred revasc?

A

surgical; PCI if poor candidate

9
Q

What scoring system is best used for tx decisions for surgical revasc of CAD?

A

STS surgical risk score. (COR1)
SYNTAX score benefit is less clear d/t interobserver variability - more useful for demonstration of complexity for PCI vs CABG decision. (2b)

10
Q

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 (angiographically intermediate)?

A

FFR >0.8 or iFR >0.89 - no benefit for revasc.
Deferring PCI assd w/ lower rates of major adverse cardiovascular event (MACE).
Of note, FFR does not seem to help improve SURGICAL outcomes.

11
Q

In pt w/ intermediate stenosis of LM artery, what can be used to help define lesion severity?

A

IVUS (2a)

12
Q

STEMI and PCI not feasible. Cardiogenic shock and/or instability despite IABP. What should be done?

A

CABG. Irrespective of time delay from MI onset (24 hrs is out of window if no ongoing ischemia).
Early revascularization is associated w/ significant survival benefit.
Specifically, the mortality at 6 mo is improved (30-day survival is not when compared to medical mgmt).

13
Q

Pt has STEMI and mechanical complication (VSD, MVR, free wall rupture), should you do CABG at the time of the surgery?

A

Yes. COR1. Goal is improving survival.
Mechanical support stabilization is often performed, but if ongoing instability or ischemia, surgery may be only option if otherwise a good candidate.

14
Q
A
15
Q

Can CABG as a primary revascularization strategy ever be considered for STEMI?

A

Yes. If PCI is not possible/unsuccessful for anatomic reasons, or even for LM or multivessel CAD. This is particularly effective if there is a large area of myocardium at risk.

16
Q

STEMI pt <12 hrs and PCI not feasible. Large area at risk and ongoing ischemia despite medical therapy and mechanical support. What is revascularization strategy?

A

Emergent/Urgent CABG (2a).
This is the only indication for EMERGENCY isolated CABG.

17
Q

Fibrinolytic therapy is recommended only in which STEMI cases?

A

primary PCI is not immediately available and the delay from hospital presentation to PCI is anticipated to be >120 minutes

18
Q

STEMI and ischemic symptoms decision making?

A

WHEN did symptoms happen: < or > 12 hrs?
<12 hrs - PCI feasible? Proceed.
<12 hrs - PCI not feasible & LARGE AREA AT RISK? CABG (irrespective of time delay)
>12 hrs - <24 hrs? PCI (2a)
>24 hrs w/ total occlusion w/o sx or severe ischemia - NO PCI (delayed PCI after 24 hrs should only be considered in pts w/ patent artery)

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.

19
Q

STEMI pt w/ failed primary PCI. Pt is asymptomatic now, the area of possible ischemia is small, and the distal targets are poor. Cardiology asking about CABG. What is the answer?

A

CABG could cause harm. CABG has a limited role in the acute phase of STEMI, and its use in this setting continues to decrease.

20
Q

Asymptomatic and stable pt w/ STEMI who presents 24 hrs after initial symptoms (resolved) w/o evidence of severe ischemia. ED calls asking for PCI. What is the answer?

A

No benefit. PCI should not be performed.

21
Q

HD stable pt w/ STEMI s/p successful primary PCI. Pt has multivessel disease. What should be done for the non-infarct significant stenosis? What is the timing?
Is there anything that could alter this plan?

A

Usually staged PCI if not complex. (1)
Low-risk w/ low-complexity lesions? -> PCI of non-culprit at same time.
Complex multivessel lesions? -> can consider CABG vs staged PCI (2a) after heart team discussion (1)

22
Q

STEMI pt s/p PCI of infarct artery. Timing of CABG for complex multivessel non-infarct disease?

A

elective - reduce risk of cardiac events (2a)

23
Q

Management for NSTE-ACS?

A

Shock? Angina? VF/VT? -> immediate/emergent revasc
GRACE >140? = high risk -> early revasc w/in 24 hrs
Initially stabilized w/ int/low risk of clinical event? - revasc before DC.

Typically, this is done with PCI, but CABG is not inferior.
Shouldn’t DC these pts.

24
Q

Although there are no randomized trials specifically evaluating emergency CABG versus medical therapy or delayed revascularization in patients with NSTE-ACS and failed PCI who have ongoing ischemia or hemodynamic compromise, multiple retrospective reviews have noted what?

A

Reduced mortality with an emergency approach.
Ie. If a coronary patient fails PCI, and they have ongoing signs of ischemia or hemodynamic compromise, these are patients who require emergency CABG.

If pt is on DAPT, appropriate safe timing of CABG is determined with a heart team. If you go for CABG, this may be a patient that should be left open and packed until bleeding stops.

25
Q

Revasc algorithm in pts w/ SIHD?

A

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)

26
Q

In pt w/ SIHD, nl EF, and 1 or 2 vessel CAD not involving LAD, what would you recommend for coronary revascularization?

A

Not recommended. Does not benefit (3).

27
Q

What SYNTAX score seems to confer CABG survival benefit over PCI for multivessel CAD?

A

SYNTAX 33

28
Q

Pt w/ previous CABG with OPEN LIMA to LAD needs repeat coronary revascularization. What approach is recommended (2a)?

A

percutaneous - open LIMA to LAD increases risk of redo sternotomy; PCI has lower stroke and mortality rate

29
Q

Pt w/ multivessel CAD is amenable to either PCI or CABG, but cannot take DAPT (access, tolerance, adherence, etc). What do you do?

A

CABG

30
Q

A patient w/ CAD is undergoing NON-cardiac surgery. They do not have LM disease, and CAD is not complex. What do you offer?

A

Do NOT recommend routine coronary revascularization - no benefit.

31
Q

ISCHEMIA-CKD randomized trial result?

A

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.

32
Q

Pt presents w/ VF/VT or cardiac arrest d/t CAD. What should be done?

A

Revascularization.
Of note… In pt w/ CAD and SCAR-RELATED sustained monomorphic VT, there is NO benefit from revascularization as the sole purpose of preventing recurrent VT

33
Q

Should you perform routine revascularization for CAD?

A

No.
It SHOULD be considered in pts w/ instability or ongoing ischemia AFTER conservative therapy.

34
Q

What should revasc stretegy be for cardiac allograft (txp) vasculopathy and severe, proximal, discrete coronary lesions?

A

PCI is reasonable

35
Q

For PCI, compare DES to BMS?

A

DES to prevent restenosis, MI or acute stent thrombosis

36
Q

In pt w/ chronic occlusion (CTO) of SVG, should PCI of SVG be done? Should it ever be done?

A

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.

37
Q

Recommendations of tx for pts w/ stent restenosis?

A

ISR w/ planned PCI - use DES (better outcomes, pt needs DAPT)
Diffuse ISR, symptoms, recurrent, indication for revasc - CABG (reduce recurrent events).

38
Q

Recommendations for antiplatelet therapy peri-PCI?

A

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.

39
Q

Periop analgesia to reduce opioid use in cardiac surgery?

A

Tylenol, ketamine, and precedex.
Regional blocks (truncal nerve).

40
Q

What mechanical vent strategy should be used for CABG to improve pulmonary mechanics and reduce postop pulm complications?

A

Intraop lung-protective strategy - TV 6-8 ml/kg predicted BW + PEEP

41
Q

In low-risk surgery, should PA catheters be recommended?

A

It is discouraged in low-risk or clinically stable pts - increased interventions and greater health care expense w/o improved MM rates.

42
Q

What intraop monitoring can help guide anesthetic decision-making and prevent neurocognitive dysfunction (such as in arch cases)?

A

Cerebral O2 sat (near infrared spectroscopy) to detect cerebral hypoperfusion

43
Q

How do you choose the arm for radial artery graft harvest?

A

Use arm w/ best ulnar arterial compensation. If equal, use non-dominant hand.

44
Q

Can radial artery be used after transradial cath?

A

should be avoided; BL perc or surgical radial artery procedures should be avoided in pts w/ CAD

45
Q

What chronic disease process should prompt the CABG surgeon to avoid radial artery graft harvesting?

A

CKD w/ high likelihood of progression to HD (need it for fistula)

46
Q

What medicine should be added in the first postop year after CABG if radial artery graft is used?

A

oral ca-channel blocker

47
Q

Best practices for use of bypass conduits in CABG?
10 points.

A

Objectively assess palmar arch completeness and ulnar compensation before harvesting the radial artery. Use the arm with the best ulnar compensation for radial artery harvest.

Use radial artery grafts to target vessels with subocclusive stenosis.

Avoid radial artery after transradial catheterization.

Avoid the use of the radial artery in patients with chronic kidney disease and a high likelihood of rapid progression to hemodialysis (preserves Cimino option).

Oral calcium channel blockers for first postop year after radial artery grafting.

Avoid bilateral perc or surgical radial artery procedures in patients with CAD to preserve the artery for future use.

Harvest IMA using skeletonized technique - reduce sternal wound complications.

Endoscopic saphenous vein harvest in those at risk of wound complications.

No-touch saphenous harvest technique in patients at low risk of wound complications.

Use skeletonized R gastroepiploic artery to graft R coronary artery target vessels with subocclusive stenosis if the operator is experienced with use of the artery.

48
Q

What technique can reduce risk of wound complications in SVG harvest?

A

endoscopic

49
Q

What technique can reduce risk of wound complications in IMA harvest?

A

skeletonized

50
Q

Best practice to reduce sternal wound infection in pts undergoing CABG?

A

Nasal swab testing for S aureus
Mupirocin 2% 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

51
Q

What level of CAD may be beneficial to revascularize if undergoing cardiac operations for other heart disease?

A

intermediate (2b) - 40-70% stenosis (as opposed to 70% non-LM and 50% LM); may reduce ischemic events; may benefit from FFR or iFR

52
Q

What intraop study is the gold standard for detection of aortic atherosclerosis and may reduce incidence of atheroembolic complications (eg stroke) in CABG?

A

epiaortic US (better than TEE and palpation) - low time, risk, and monetary cost

53
Q

In terms of CPB, what technique can be used to decrease the risk of perioperative stroke in pt w/ significant aortic calcification?

A

off-pump CAB - avoids aortic manipulation (2a); may also be beneficial for pts w/ significant pulm disease (2b)

54
Q

What is the glucose goal in intraop CABG pts?

A

<180. Use an insulin infusion. Same as postop goal.
Decreases sternal wound infection rate.

55
Q

A pt undergoing CABG asks if they need to stop ASA preop? What about other antiplatelets?

A

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.

56
Q

In pts undergoing elective CABG not already on ASA, should it be started immediately preop?

A

No. No benefit 24 hrs before surgery.

57
Q

Can preop amiodarone help CABG pts?

A

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.

58
Q

When should ASA be started after CABG?

A

within 6 hrs postop;
of note, select pts may benefit from DAPT if vein grafts are in bad targets

Initiation of aspirin therapy in the immediate preoperative period (<24 hours) has been investigated in 2 randomized trials. In the first trial,24 patients undergoing CABG who received 100 mg of aspirin 1 to 2 hours before surgery experienced a composite outcome of death and thrombotic complications at 30 days and an incidence of major bleeding and cardiac tamponade that were similar to those seen with placebo.24 In the second trial,25 patients randomized to receive 300 mg of aspirin the night before surgery had increased episodes of major bleeding (>750 mL in 24 hours, or 1000 mL overall) and increased transfusion rates, but no significant differences were found in major cardiovascular events at early (30 days) or long-term (36 months) time points compared with placebo.

59
Q

Should postop beta blockers be used in CABG?

A

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.

60
Q

A-fib after CABG risk and complications?

A

18% rate after CABG. 4x inc stroke risk. 3x inc all mortality.

61
Q

Benefit for postop CABG cardiac rehab?

A

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.

62
Q

Role for psychological treatment in coronary revascularization?

A

COR 1 recommendation to treat depression, anxiety, or stress w/ CBT, counseling, or medicine to improve QoL and outcomes.

63
Q

What is recommended to maximize smoking cessation and reduce adverse cardiac events in tobacco users after coronary revascularization?

A

combo behavioral and pharm therapy; start during hospitalization and f/u 1 mo after DC to facilitate; reduces M&M

64
Q

What major pathologies are not calculated in the STS risk score? How else are they evaluated?

A

Cirrhosis - MELD.
Frailty - gait speed.
Malnutrition - MUST.

65
Q

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?

A

CABG. COR1.
STICH trial - ICM and LVEF <35 randomized to CABF vs optimal med therapy. CABG resulted in lower 10-year risk of all-cause mortality.

66
Q

Manage SCAD (spontaneous coronary artery DISSECTION).

A

If hemodynamic instability or ongoing ischemia despite conservative therapy, revascularization may be considered (2b).
Routine revascularization should not be performed (3:harm).

67
Q

In patients with chronic occlusion of an SVG (previous CABG), percutaneous revascularization of the SVG should be done?

A

No. (3: harm)

68
Q

For CABG, what strategy may improve outcomes for patients with increased pulmonary risk?

A

Off-pump CABG has been shown to be associated with earlier extubation, reduced blood transfusion, and reduced duration of mechanical ventilation compared with on-pump CABG and may improve outcomes for patients with increased pulmonary risk, which is perhaps related to avoidance of the systemic inflammatory response attributable to cardiopulmonary bypass and its impact on pulmonary function.

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