What are the surgical revascularization strategies after acute coronary syndrome?

Surgical Revascularization Strategies After Acute Coronary Syndrome

Immediate coronary angiography followed by appropriate revascularization is the cornerstone of management for high-risk patients with acute coronary syndrome, with percutaneous coronary intervention (PCI) preferred for single-vessel disease and coronary artery bypass grafting (CABG) recommended for left main or triple-vessel disease, particularly in patients with left ventricular dysfunction. 1

Risk Stratification and Timing of Intervention

• Patients with ACS should be risk-stratified to determine the optimal revascularization strategy and timing 1

• High-risk patients requiring urgent revascularization include:

  • Those with recurrent ischemia (recurrent chest pain or dynamic ST changes) 1
  • Elevated troponin levels 1
  • Hemodynamic instability or cardiogenic shock 1
  • Major arrhythmias (repetitive ventricular tachycardia, ventricular fibrillation) 1
  • Early post-infarction unstable angina 1
  • Patients with diabetes mellitus 1

• Timing of intervention:

  • Immediate revascularization (within first hour) for patients with severe ongoing ischemia, major arrhythmias, or hemodynamic instability 1
  • Within 24-48 hours for high-risk NSTE-ACS patients without immediate indications 1, 2
  • For STEMI patients, primary PCI should be performed within 120 minutes of presentation 2

Revascularization Strategies Based on Clinical Presentation

STEMI Patients

• Primary PCI is the preferred strategy for STEMI patients presenting within 12 hours of symptom onset or up to 24 hours if clinical instability is present 1
• If PCI cannot be performed within 120 minutes, fibrinolytic therapy should be administered followed by transfer for PCI within 24 hours 2
• For patients initially treated with fibrinolysis:
  • Immediate revascularization is appropriate for suspected failed fibrinolysis 1
  • PCI performed 3-24 hours after successful fibrinolysis is appropriate for stable patients 1
  • PCI >24 hours after STEMI onset may be appropriate in stable patients 1

NSTEMI/Unstable Angina Patients

• Immediate revascularization is appropriate for patients with cardiogenic shock 1
• Early revascularization (within 24-48 hours) is appropriate for stabilized patients with intermediate or high-risk features (e.g., TIMI score 3-4) 1, 2
• Revascularization may be appropriate for stabilized patients with low-risk features (e.g., TIMI score ≤2) 1

Selection of Revascularization Method (PCI vs. CABG)

• The decision regarding the most appropriate revascularization procedure should be made after careful evaluation of the extent and characteristics of the lesions 1

• PCI is preferred for:

  • Single-vessel disease with identifiable culprit lesion 1
  • STEMI patients requiring immediate reperfusion 1, 2
  • Some cases of double-vessel disease 1

• CABG is recommended for:

  • Left main disease 1
  • Triple-vessel disease, particularly with left ventricular dysfunction 1
  • Complex multivessel coronary artery disease 1, 3
  • Diabetes with multivessel disease 1

• Staged procedures may be considered in some patients, with immediate PCI of the culprit lesion followed by reassessment for treatment of other lesions 1

Management of Non-Culprit Lesions

• For patients with STEMI and multivessel disease, the following approaches to non-culprit lesions are recommended:
  • Immediate revascularization of non-culprit arteries is appropriate in cardiogenic shock persisting after PCI of the culprit artery 1
  • Revascularization of non-culprit arteries during the same hospitalization is appropriate for patients with:
    • Spontaneous or easily provoked symptoms of myocardial ischemia and severe stenoses 1
    • Asymptomatic patients with ischemia on non-invasive testing and severe stenoses 1
    • Asymptomatic patients with intermediate stenoses and FFR ≤0.80 1
  • Revascularization of non-culprit arteries during the same procedure as culprit PCI may be appropriate in stable patients 1

Outcomes and Considerations

• Surgical revascularization for ACS is associated with substantial in-hospital mortality (8.1% overall), with highest rates in STEMI patients (12.6%) 3
• Key predictors of poor outcomes with CABG in ACS include female gender, elevated troponin, reduced left ventricular ejection fraction, need for inotropic support, and emergency surgery 3
• Patients with ACS and multivessel disease have significantly higher cardiovascular morbidity and mortality compared to those with single-vessel disease 4

Caveats and Pitfalls

• Delaying revascularization beyond recommended timeframes increases mortality risk, especially in high-risk patients 2
• Failure to recognize the need for CABG in complex multivessel disease may lead to suboptimal outcomes with PCI alone 1
• Performing PCI on non-culprit lesions without evidence of ischemia or functional significance (FFR) is rarely appropriate 1
• Emergency CABG for ACS is associated with poorer outcomes and should be carefully considered against the risks of delayed intervention 3
• Antiplatelet therapy management is critical - clopidogrel should be stopped approximately 5 days before CABG if the operation can be safely deferred 1