Unstable angina / non ST elevation myocardial infarction post CABG patients

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Risk calculators and risk factors for Unstable angina / non ST elevation myocardial infarction post CABG patients

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Post-CABG patients with unstable angina or NSTEMI are associated with a more severe coronary artery disease compared to the patients who have not undergone a bypass surgery. Medical treatment in this patient population should follow the same guidelines as for UA/NSTEMI in non–post CABG patients.

Post CABG Patients with UA / NSTEMI

  • Post-CABG patients who present with UA/NSTEMI are at higher risk, with more extensive CAD and LV dysfunction than those patients who have not previously undergone surgery.
  • Obstructive lesions are more likely to occur in the saphenous vein grafts as compared to internal mammary artery grafts.
  • Symptomatically, these patients have more prolonged chest pain than ACS patients without prior CABG. A lot of these patients have resting ECG abnormalities and hence ECG stress tests are less conclusive. Imaging is therfore helpful.
  • Coronary intervention in these patients can also be challenging specially as these patients have high rate of embolization of atherosclerotic material from friable grafts at the time of intervention, thereby also increasing post procedural complications. When intervention is performed, current available results from randomized trials have shown no significant difference in the rate of restenosis in these patients when compared to general population.

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [1]

Recommendations for Post–CABG

Class I
"1.Patients with prior CABG and NSTE-ACS should receive antiplatelet and anticoagulant therapy according to GDMT and should be strongly considered for early invasive strategy because of their increased risk (Level of Evidence: B)"

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[2]

Post-CABG Patients (DO NOT EDIT)[2]

Class I
"1. Medical treatment for UA / NSTEMI patients after CABG should follow the same guidelines as for non–post CABG patients with UA / NSTEMI. (Level of Evidence: C)"
"2. Because of the many anatomic possibilities that might be responsible for recurrent ischemia, there should be a low threshold for angiography in post CABG patients with UA / NSTEMI. (Level of Evidence: C)"
Class IIa
"1. Repeat CABG is reasonable for UA / NSTEMI patients with multiple SVG stenoses, especially when there is significant stenosis of a graft that supplies the LAD. PCI is reasonable for focal saphenous vein graft stenosis. (Level of Evidence: C) (Note that an intervention on a native vessel is generally preferable to that on a vein graft that supplies the same territory, if possible.)"
"2. Stress testing with imaging in UA / NSTEMI post CABG patients is reasonable. (Level of Evidence: C)"

References

  1. Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
  2. 2.0 2.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.". Circulation. 123 (18): e426–579. PMID 21444888. doi:10.1161/CIR.0b013e318212bb8b. 



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