What testing is recommended for an 82-year-old male with a history of CAD and CABG?

Testing Recommendations for an 82-Year-Old Male with CAD s/p CABG

For an 82-year-old male with CAD s/p CABG x 3 in 2020 with no ongoing chest pain, stress imaging (PET/SPECT, CMR, or echocardiography) is recommended to evaluate for myocardial ischemia or graft stenosis/occlusion. 1

Rationale for Testing Selection

Asymptomatic Post-CABG Patient Considerations

1. Timing since CABG surgery:

   • This patient had CABG 3 years ago (in 2020)
   • Guidelines suggest that routine non-invasive imaging-based stress testing may be considered after 1 year post-PCI and >5 years after CABG 1
   • However, for high-risk patients, surveillance testing may be appropriate sooner

2. Patient-specific factors:

   • Advanced age (82 years) represents a higher-risk category
   • History of multivessel disease requiring 3-vessel CABG
   • These factors may warrant earlier surveillance testing despite being asymptomatic

Specific Testing Recommendations

First-line Testing:

• Stress imaging (PET/SPECT, CMR, or echocardiography) is the preferred initial test 1
  • Superior to exercise ECG for detecting ischemia in post-revascularization patients
  • Can identify both perfusion defects and wall motion abnormalities
  • Helps assess both graft patency and progression of native vessel disease

When to Consider Coronary CT Angiography (CCTA):

• CCTA may be considered as an alternative to assess graft patency 1
• However, CCTA has limitations in post-CABG patients:
  • Less robust for assessing native coronary vessel stenosis due to high degree of calcification
  • Higher rate of non-diagnostic segments in post-CABG patients 1

When to Consider Invasive Coronary Angiography (ICA):

• ICA is not recommended as an initial test in asymptomatic patients
• Should be reserved for patients with:
  • Moderate-to-severe ischemia on non-invasive testing
  • Indeterminate/non-diagnostic stress test results 1

Interpretation of Results and Next Steps

High-Risk Findings on Stress Testing:

• Ischemia at low workload with exercise stress testing
• Early-onset ischemia with pharmacological stress
• Inducible wall motion abnormality
• Reversible perfusion defect in ≥10% of LV myocardium 1

Management Based on Test Results:

1. Negative test: Continue optimal medical therapy and routine follow-up

   • Consider repeat testing in 1-2 years given patient's age and disease complexity

2. Positive test with moderate-severe ischemia: Proceed to invasive coronary angiography

   • ICA is recommended for guiding therapeutic decision-making in patients with moderate-to-severe ischemia 1

3. Indeterminate results: Consider alternative imaging modality or proceed to ICA based on clinical judgment

Important Considerations and Caveats

• Routine testing without clinical indication may not be beneficial: The ROSETTA-CABG Registry showed that routine functional testing 1 year after CABG was not associated with improved outcomes compared to a symptom-driven approach 2

• Symptom monitoring remains important: Despite being currently asymptomatic, the patient should be educated about promptly reporting any new or recurrent symptoms

• Medical therapy optimization: Ensure the patient is on optimal guideline-directed medical therapy for secondary prevention regardless of testing strategy

• Avoid unnecessary testing: Testing should be performed only if results would change management decisions

• Age considerations: In elderly patients (>80 years), the risks and benefits of additional interventions following abnormal test results should be carefully weighed, as operative mortality rates for repeat CABG in patients ≥80 years range from 5-8% 1