Medication Summary
The aims of premedication are to minimize myocardial oxygen demands by reducing the heart rate and systemic arterial pressure and to improve myocardial blood flow with vasodilators.
See the 2017 European Association for Cardio-Thoracic Surgery (EACTS) guidelines on perioperative medication in adult cardiac surgery [69] for more information.
Anxiolytics, Benzodiazepines
Class Summary
Administration of temazepam immediately before CABG can decrease the risk of tachycardia and hypertension resulting from anxiety regarding the operation. In the operating room, intravenous (IV) administration of a small dose of midazolam before arterial line insertion can also reduce anxiety, tachycardia, and hypertension.
Temazepam (Restoril)
Temazepam depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing the activity of GABA.
Midazolam
Midazolam is a short-acting benzodiazepine with a rapid onset of action.
Opioid Analgesics
Class Summary
Induction of anesthesia is accomplished by using high doses of opioid (usually fentanyl or remifentanil) to minimize the dose of propofol, etomidate, or thiopental and thereby maximize cardiovascular stability.
Fentanyl citrate (Duragesic, Abstral, Actiq, Fentora, Onsolis)
Fentanyl citrate is a synthetic opioid that has 75-200 times more potency and a much shorter half-life than morphine sulfate. It has fewer hypotensive effects than morphine and is safer in patients with hyperactive airway disease because of minimal or no associated histamine release. By itself, fentanyl citrate causes little cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Fentanyl citrate is highly lipophilic and protein-bound. Prolonged exposure to it leads to accumulation of the drug in fat and delays the weaning process. Consider continuous infusion because of the medication's short half-life.
Remifentanil (Ultiva)
Remifentanil binds mu-opioid receptors at various sites within the CNS.
Anesthetic Agents
Class Summary
After standard monitoring equipment is attached and peripheral venous access achieved but before the arterial line is inserted, the midazolam dose is administered. Before placement of the arterial line, it should be ensured that a radial artery graft will not be used for CABG.
Propofol (Diprivan)
Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic properties when administered intravenously. Propofol IV produces rapid hypnosis, usually within 40 seconds. The effects are reversed within 30 minutes, following the discontinuation of infusion. Propofol has also been shown to have anticonvulsant properties.
Etomidate (Amidate)
Amidate is a nonbarbiturate imidazole compound with sedative properties. It is short-acting and has a rapid onset of action; the duration of action is dose dependent (15-30 minutes). Its most useful feature as an induction agent is that it produces deep sedation while causing minimal cardiovascular effects.
The major application of amidate is induction for endotracheal intubation, particularly in patients with, or at risk for, hemodynamic compromise. Amidate has been shown to depress adrenal cortical function; however, this effect is not significant clinically during short-term administration. Since the drug is mixed in propylene glycol, continuous infusion is not recommended.
Thiopental
Thiopental is a short-acting barbiturate sedative-hypnotic with rapid onset and a duration of action of 5-20 minutes. Like methohexital, it is most commonly used as an induction agent for intubation. To use thiopental as a sedative, titrate in dosage increments of 25 mg (adjust to lower dose in children).
Isoflurane (Forane, Terrell)
Isoflurane is an inhalation anesthetic. It may have a myocardial protective effect and therefore is especially useful in off-pump surgery. Isofluranse potentiates the effects of muscle relaxants. Small doses of muscle relaxants can achieve complete paralysis when administered concomitantly with isoflurane.
Neuromuscular Blockers, Nondepolarizing
Class Summary
Nondepolarizing neuromuscular blockers are used in combination with a sedative as part of the rapid-sequence intubation process.
Pancuronium
Vecuronium may increase myocardial oxygen demand. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
Vecuronium
Vecuronium may cause bradycardia in association with opioids. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
Rocuronium (Zemuron)
Rocuronium may cause tachycardia. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
Atracurium
Atracurium is not considered suitable for operations of long duration. It can cause hypotension secondary to histamine release. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
Anticoagulants, Hematologic
Class Summary
Anticoagulants prevent recurrent or ongoing thromboembolic occlusion of the vertebrobasilar circulation.
Heparin
Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. It prevents the recurrence of a clot after spontaneous fibrinolysis.
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Coronary Artery Bypass Grafting. Illustration of a median sternotomy.
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Coronary Artery Bypass Grafting. Illustration of an internal thoracic (mammary) artery (IMA) harvest as a pedicle.
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Coronary Artery Bypass Grafting. Illustration of the open saphenous vein harvest technique.
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Coronary Artery Bypass Grafting. Cannulation, illustrated.
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Coronary Artery Bypass Grafting. Illustration of the distal anastomotic technique.
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Coronary Artery Bypass Grafting. Illustration of the proximal anastomotic technique.
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Coronary Artery Bypass Grafting. This video demonstrates coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest. Video courtesy of Dale K Mueller, MD.
Tables
- Table 1. ACC/AHA Indications for Coronary Artery Bypass Grafting [2, 3]
- Table 2. Treatment Recommendations for Patients with Acute Heart Failure in Setting of Acute Myocardial Infarction
- Table 3. Specific Treatment Recommendations for Coronary Artery Disease in Patients with Mild to Moderate Chronic Kidney Disease
- Table 4. Specific Treatment Recommendations for Coronary Artery Disease in Diabetic Patients
- Table 5. Recommendations for Combining Valve Surgery and Coronary Artery Bypass Grafting
- Table 6. Carotid Revascularization in Patients Scheduled for Coronary Artery Bypass Grafting
- Table 7. Management of Patients with Associated Coronary and Peripheral Arterial Disease
- Table 8. Management of Patients with Renal Artery Stenosis
- Table 9. Recommendations for Patients with Chronic Heart Failure and Systolic Left Ventricular Dysfunction (Ejection Fraction = 35%), Presenting Predominantly with Angina Symptoms
- Table 10. Recommendations for Patients with Chronic Heart Failure and Systolic Left Ventricular Dysfunction (Ejection Fraction = 35%), Presenting Predominantly with Heart Failure Symptoms (No or Mild Angina: Canadian Cardiovascular Society 1-2)
- Table 11. Technical Recommendations for Coronary Artery Bypass Grafting
- Table 12. Multidisciplinary Decision Pathways, Patient Informed Consent, and Timing of Intervention [28]
- Table 13. Indications for Coronary Artery Bypass Grafting
- Table 14. Updated ACC/AHA/SCAI Recommendations for Revascularization for Survival Improvement in Stable Ischemic Heart Disease Versus Medical Therapy [1]
- Table 15. Preoperative management of antiplatelet therapy in patients undergoing CABG
- Table 16. Postoperative management of antiplatelet therapy in patients undergoing CABG
Indication |
Asymptomatic or Mild Angina |
Stable Angina |
Unstable Angina/ NSTEMI |
Poor Left Ventricular Function |
Left main stenosis >50% |
Class I |
Class I |
Class I |
Class I |
Stenosis of proximal LAD and proximal circumflex artery >70% |
Class I |
Class I |
Class I |
Class I |
3-Vessel disease |
Class I |
Class I |
|
Class I, with proximal LAD stenosis |
2-Vessel disease |
|
Class I if there is a large area of viable myocardium in a high-risk area; Class IIa if there is a moderate viable area and ischemia |
Class IIb |
|
With >70% proximal LAD stenosis |
Class IIa |
Class I with either an ejection fraction < 50% or demonstrable ischemia on noninvasive testing |
Class IIa |
Class I |
Involving proximal LAD |
Class IIb |
|
|
|
1-Vessel disease |
|
Class I if there is a large area of viable myocardium in a high-risk area; Class IIa, if there is a viable moderate area and ischemia |
Class IIb |
|
With >70% proximal LAD stenosis |
Class IIa |
Class IIa |
Class IIa |
|
Involving proximal LAD |
Class IIb |
|
|
|
ACC = American College of Cardiology; AHA = American Heart Association; LAD = left anterior descending (artery); NSTEMI = non–ST-segment elevation myocardial infarction. |
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|
Class of Recommendation |
Level of Evidence |
Patients with NSTE-ACS or STEMI and unstable hemodynamics should immediately be transferred for invasive evaluation and target vessel revascularization |
Class I |
A |
Immediate reperfusion is indicated in acute heart failure with ongoing ischemia |
Class I |
B |
Echocardiography should be performed to assess LV function and to exclude mechanical complications |
Class I |
C |
Emergency angiography and revascularization of all critically narrowed arteries by PCI/CABG as appropriate is indicated in patients in cardiogenic shock |
Class I |
B |
IABP insertion is recommended in patients with hemodynamic instability (particularly those in cardiogenic shock and with mechanical complications) |
Class I |
C |
Surgery for mechanical complications of AMI should be performed as soon as possible with persistent hemodynamic deterioration despite IABP |
Class I |
B |
Emergency surgery after failure of PCI or fibrinolysis is indicated only in patients with persistent hemodynamic instability or life-threatening ventricular arrhythmia due to extensive ischemia (left main or severe 3-vessel disease) |
Class I |
C |
If the patient continues to deteriorate without adequate cardiac output to prevent end-organ failure, temporary mechanical assistance (surgical implantation of LVAD/BiVAD) should be considered |
Class IIa |
C |
Routine use of percutaneous centrifugal pumps is not recommended |
Class III |
B |
AMI = acute myocardial infarction; BiVAD = biventricular assist device; CABG = coronary artery bypass grafting; IABP = intra-aortic balloon pump; LV = left ventricle; LVAD = left ventricular assist device; NSTE-ACS = non–ST-segment elevation acute coronary syndrome; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. |
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|
Recommendation |
Level of Evidence |
CABG should be considered, rather than PCI, when the extent of CAD justifies a surgical approach, the patient’s risk profile is acceptable, and the life expectancy is reasonable |
Class IIa |
B |
Off-pump CABG may be considered rather than on-pump CABG |
Class IIb |
B |
For PCI, drug-eluting stents may be considered, rather than bare metal stents |
Class IIb |
C |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; PCI = percutaneous coronary intervention. |
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|
Recommendation |
Level of Evidence |
In patients presenting with STEMI, primary PCI is preferred over fibrinolysis if it can be performed within recommended time limits |
Class I |
A |
In stable patients with extensive CAD, revascularization is indicated to improve MACCE-free survival |
Class I |
A |
Use of drug-eluting stents is recommended to reduce restenosis and repeat target vessel revascularization |
Class I |
A |
In patients on metformin, renal function should be carefully monitored after coronary angiography/PCI |
Class I |
C |
CABG should be considered, rather than PCI, when the extent of CAD justifies a surgical approach (especially multivessel disease) and the patient’s risk profile is acceptable |
Class IIa |
B |
In patients with known renal failure undergoing PCI, metformin may be stopped 48 hours before the procedure |
Class IIb |
C |
Systematic use of glucose insulin potassium in diabetic patients undergoing revascularization is not indicated |
Class III |
B |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; MACCE = major adverse cardiac and cerebral event; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. |
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|
Recommendation |
Level of Evidence |
In combination with valve surgery: |
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CABG is recommended in patients with a primary indication for aortic/mitral valve surgery and coronary artery stenosis = 70% |
Class I |
C |
CABG should be considered in patients with a primary indication for aortic/mitral valve surgery and coronary artery stenosis of 50-70% |
Class IIa |
C |
In combination with CABG: |
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Mitral valve surgery is indicated in patients with a primary indication for CABG and severe ischemic mitral regurgitation and an EF >30%* |
Class I |
C |
Mitral valve surgery should be considered in patients with a primary indication for CABG and moderate ischemic mitral regurgitation, provided that valve repair is feasible and performed by experienced operators |
Class IIa |
C |
Aortic valve surgery should be considered in patients with a primary indication for CABG and moderate aortic stenosis (mean gradient 30-50 mm Hg, Doppler velocity of 3-4 m/sec, or heavily calcified aortic valve even with Doppler velocity of 2.5-3 m/sec) |
Class IIa |
C |
* Definition of severe mitral regurgitation is at http://www.escardio.org/guidelines. CABG = coronary artery bypass grafting; EF = ejection fraction. |
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|
Recommendation |
Level of Evidence |
CEA or CAS should be performed only by teams with demonstrated 30-day combined death-stroke rates of < 3% in patients without previous neurologic symptoms and < 6% in patients with previous neurologic symptoms |
Class I |
A |
Indication for carotid revascularization should be individualized after discussion by a multidisciplinary team, including a neurologist |
Class I |
C |
Timing of procedures (synchronous or staged) should be dictated by local expertise and clinical presentation, with the most symptomatic territory targeted first |
Class I |
C |
In patients with previous TIA/nondisabling stroke: |
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Carotid revascularization is recommended for 70-99% carotid stenosis |
Class I |
C |
Carotid revascularization may be considered for 50-69% carotid stenosis in men with symptoms of < 6 months |
Class IIb |
C |
Carotid revascularization is not recommended if carotid stenosis is < 50% in men and < 70% in women |
Class III |
C |
In patients with no previous TIA/stroke: |
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Carotid revascularization may be considered in men with bilateral 70-99% carotid stenosis or 70-99% carotid stenosis and contralateral occlusion |
Class IIb |
C |
Carotid revascularization is not recommended in women or patients with a life expectancy < 5 years |
Class III |
C |
CAS = carotid artery stenting; CEA = carotid endarterectomy; TIA = transient ischemic attack. |
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|
Recommendation |
Level of Evidence |
In patients with unstable CAD, vascular surgery is postponed and CAD treated first, except when vascular surgery cannot be delayed because of a life-threatening condition |
Class I |
B |
Beta-blockers and statins are indicated preoperatively and should be continued postoperatively in patients with known CAD who are scheduled for high-risk vascular surgery |
Class I |
B |
The choice between CABG and PCI should be individualized and assessed by the heart team taking into account the patterns of CAD, PAD, comorbidity, and clinical presentation |
Class I |
C |
Prophylactic myocardial revascularization before high-risk vascular surgery may be considered in stable patients if they have persistent signs of extensive ischemic or high cardiac risk |
Class IIb |
B |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; PAD = peripheral arterial disease; PCI = percutaneous coronary intervention. |
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|
Recommendation |
Level of Evidence |
Functional assessment of renal artery stenosis severity using pressure gradient measurements may be useful in selecting hypertensive patients who may benefit from renal artery stenting |
Class IIb |
B |
Routine renal artery stenting to prevent deterioration of renal function is not recommended |
Class III |
B |
|
Recommendation |
Level of Evidence |
CABG is recommended for the following:
|
Class I |
B |
CABG with surgical ventricular reconstruction may be considered in patients with LVESV index = 60 mL/m2 and scarred left anterior descending territory |
Class IIb |
B |
PCI may be considered in the presence of viable myocardium if the anatomy is suitable |
Class IIb |
C |
CABG = coronary artery bypass grafting; LVESV = left ventricular end-systolic volume; PCI = percutaneous coronary intervention. |
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|
Recommendation |
Level of Evidence |
LV aneurysmectomy during CABG is indicated in patients with a large LV aneurysm |
Class I |
C |
CABG should be considered in the presence of viable myocardium, irrespective of the LVESV |
Class IIa |
B |
CABG with SVR may be considered in patients with scarred LAD territory |
Class IIb |
B |
PCI may be considered in the presence of viable myocardium if the anatomy is suitable |
Class IIb |
C |
Revascularization in the absence of evidence of myocardial viability is not recommended |
Class III |
B |
CABG = coronary artery bypass grafting; LAD = left anterior descending (artery); LV = left ventricle; LVESV = left ventricular end-systolic volume; PCI = percutaneous coronary intervention; SVR = surgical ventricular reconstruction. |
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|
Recommendation |
Level of Evidence |
Procedures should be performed in a hospital structure and by a team specialized in cardiac surgery, using written protocols |
Class I |
B |
Arterial grafting to the LAD system is indicated |
Class I |
A |
Complete revascularization with arterial grafting to a non-LAD coronary system is indicated in patients with a reasonable life expectancy |
Class I |
A |
Minimization of aortic manipulation is recommended |
Class I |
C |
Graft evaluation is recommended before departure from the operating theater |
Class I |
C |
LAD = left anterior descending (artery). |
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|
Acute Coronary Syndrome
|
Stable Multivessel Disease |
Stable with Indication for Ad Hoc PCI |
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|
Shock |
STEMI |
NSTE-ACS |
Other ACS |
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Multidisciplinary decision making |
Not mandatory |
Not mandatory |
Not required for culprit lesion but required for nonculprit vessel(s) |
Required |
Required |
According to predefined protocols |
Informed consent |
Oral witnessed informed consent or family consent if possible without delay |
Oral witnessed informed consent may be sufficient unless written consent is legally required |
Written informed consent* (if time permits) |
Written informed consent* |
Written informed consent* |
Written informed consent* |
Time to revascularization |
Emergency: No delay |
Emergency: No delay |
Urgency: Within 24 h if possible and no later than 72 h |
Urgency: Time constraints apply |
Elective: No time constraints |
Elective: No time constraints |
Procedure |
Proceed with intervention on basis of best evidence/ availability |
Proceed with intervention on basis of best evidence/availability |
Proceed with intervention on basis of best evidence/ availability; nonculprit lesions treated according to institutional protocol |
Proceed with intervention on basis of best evidence/ availability; nonculprit lesions treated according to institutional protocol |
Plan most appropriate intervention, allowing enough time from diagnostic catheterization to intervention |
Proceed with intervention according to institutional protocol defined by local heart team |
* May not apply to countries that legally do not ask for written informed consent, although European Society of Cardiology and European Association for Cardiothoracic Surgery strongly advocate documentation of patient consent for all revascularization procedures. ACS = acute coronary syndrome; NSTE-ACS = non–ST-segment elevation acute coronary syndrome; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. |
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Indication |
ACC/AHA |
ESC/EACT |
Left main disease |
Class I |
Class I |
Three-vessel disease with or without proximal LAD artery disease |
Class I |
Class I |
Two-vessel disease with proximal LAD artery disease |
Class I |
Class I |
Two-vessel disease without proximal LAD artery disease |
Class IIa (with extensive ischemia) |
Class IIb |
Single-vessel disease with proximal LAD artery disease |
Class IIa (with LIMA for long-term benefit) |
Class I |
Single-vessel disease without proximal LAD artery disease |
Class III—Harmful |
Class IIb |
LV Dysfunction |
Class IIa (EF 35% to 50%) Class IIb (EF< 35%) |
Class I (EF< 40%) |
Survivors of sudden cardiac death with presumed ischemia-mediated VT |
Class I |
Class I |
LAD = left anterior descending (artery); LV = left ventricle; LIMA= left internal mammary artery EF = ejection fraction; VT = ventricular tachycardia |
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| Recommendation | Level of Evidence | |
|---|---|---|
LV dysfunction and multivessel CAD |
||
| Patients with SIHD and multivessel CAD appropriate for CABG with severe LV systolic dysfunction (LVEF < 35%) | Class I | B |
| Selected patients with SIHD and multivessel CAD appropriate for CABG and mild-to-moderate LV systolic dysfunction (LVEF of 35-50%): CABG (to include a LIMA graft to the LAD) is reasonable | Class IIa | B |
Left main CAD |
||
| Patients with SIHD and significant left main stenosis | Class I | B |
| Patients with SIHD and significant left main stenosis for whom revascularization with PCI can provide equivalent to that possible with CABG: PCI is reasonable | Class IIa | B |
Multivessel CAD |
||
| Patients with SIHD, normal EF, significant stenosis of 3 major coronary arteries (± proximal LAD), and suitable anatomy for CABG: CABG may be reasonable | Class IIb | B |
| Patients with SIHD, normal EF, significant stenosis of 3 major coronary arteries (± proximal LAD), and suitable anatomy for PCI: PCI utility is uncertain | Class IIb | B |
Stenosis in the proximal LAD artery |
||
| Patients with SIHD, normal LVEF, and significant stenosis in the proximal LAD: coronary revascularization utility is uncertain | Class IIb | B |
Single- or double-vessel disease not involving the proimal LAD |
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| Patients with SIHD, normal LVEF, and 1- or 2-vessel CAD not involving the proximal LAD: coronary revascularization not recommended | Class III | B |
| Patients with SIHD with ≥1 coronary arteries that are not anatomically or functionally significant (< 70% diameter of non–left main coronary artery stenosis, FFR >0.80): Do not perform coronary revascularization with the primary or sole intent to improve survival | Class III | B |
CABG = coronary artery bypass grafting; CAD = coronary artery disease; EF = ejection fraction; FFR = fractional flow reserve; LAD = left anterior descending (artery); LIMA = Left internal mammary artery; LV = left ventricle; PCI = percutaneous coronary intervention; SIHD = stable ischemic heart disease. |
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Recommendation |
2011 ACC/AHA |
2012 ACC/AHA |
2014 ACC/AHA |
2014 ESC/EACT |
2012 STS |
Administer aspirin to CABG patients preoperatively |
(100 mg to 325 mg daily) Class I |
Class I |
(81–325 mg daily) Class I |
(75–160 mg daily) Class I |
|
In patients at increased risk for bleeding and those who refuse blood transfusion, discontinue aspirin 3-5 days prior to surgery |
Class I |
Class IIa |
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For non-urgent CABG, discontinue clopidogrel and ticagrelor for at least 5 days before surgery and prasugrel for at least 7 days to limit blood transfusions |
Class I |
Class I |
Class I |
Class I |
|
In patients referred for urgent CABG, discontinue clopidogrel and ticagrelor for at least 24 hours to reduce major bleeding complications |
Class I |
Class I |
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In patients referred for urgent CABG, discontinue eptifibatide and tirofiban for at least 2-4 hours and abciximab for at 12 hours |
Class I |
(Discontinue eptifibatide and tirofiban 4 hours) Class I |
Class I |
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Anticoagulant therapy: unfractionated heparin; discontinue enozaparin 12-24 hours; discontinue fondaparinux for 24 hours; discontinue bivalirudin for 3 hours |
Class I |
Recommendation |
2011 ACC/AHA |
2014 ACC/AHA |
2014 ESC/EACT |
2012 STS |
Administer aspirin to CABG patients indefinitely |
100 mg to 325 mg daily - Class I |
81–325 mg daily (Only 81 mg with ticagrelor) Class I |
75–160 mg daily Class I |
Class I |
Administer clopidogrel or ticagrelor, in addition to aspirin, for 12 months |
Class I |
Class IIb |
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Clopidogrel (75 mg daily) is a reasonable alternative in patients intolerant or allergic to aspirin |
Class IIa |
Class I |
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In CABG after acute coronary syndromes, restart dual antiplatelet therapy when bleeding risk is diminished. |
Class I |
|||
Once postoperative bleeding risk is decreased, consider testing of response to antiplatelet drugs, either with genetic testing or with point-of-care platelet function testing, to optimize antiplatelet drug effect and minimize thrombotic risk to vein grafts |
Class IIb |
