What are the recommendations for surgical revascularization after Acute Coronary Syndrome (ACS)?

Surgical Revascularization After Acute Coronary Syndrome

Patients with ACS should undergo appropriate coronary revascularization based on clinical presentation and coronary anatomy, with surgery (CABG) specifically recommended for those with left main disease or complex multivessel disease, particularly in diabetic patients. 1

Indications for Revascularization After ACS

• Immediate coronary revascularization (PCI or CABG) is recommended for all patients with ACS who have:

  • ST-segment elevation myocardial infarction (STEMI) 1
  • High-risk non-ST-elevation myocardial infarction (NSTEMI) 1
  • Cardiogenic shock 1
  • Refractory angina, intractable arrhythmias, or hemodynamic instability 1
  • GRACE scores >140 1

• For patients with ACS requiring non-cardiac surgery, coronary revascularization should be performed first and the non-cardiac surgery deferred to reduce perioperative cardiovascular events 1

Choice of Revascularization Method (PCI vs. CABG)

CABG is Recommended For:

• Patients with significant left main disease to improve survival compared to medical therapy 1
• Patients with triple-vessel CAD (especially with diabetes) 1
• Patients with complex multivessel disease with high SYNTAX scores 1, 2
• Diabetic patients with multivessel disease 1, 2

PCI is Recommended For:

• Single-vessel disease, particularly the culprit lesion in ACS 1
• Selected patients with left main disease with low-to-medium anatomic complexity 1, 2
• Patients who are poor candidates for surgery due to comorbidities 1

Timing of Revascularization in ACS

• For very high-risk ACS patients (hemodynamic instability, refractory angina, life-threatening arrhythmias), an immediate invasive strategy (<2 hours) is recommended 2
• For high-risk ACS patients, an early invasive strategy (<24 hours) is recommended 2
• For STEMI patients, immediate primary PCI of the culprit lesion is the standard approach 1
• For multivessel disease in ACS, a complete revascularization strategy is recommended, which may be performed:
  • In a single procedure for selected stable patients 1, 3
  • As a staged procedure (culprit lesion first, followed by non-culprit lesions) 1, 4

Special Considerations

• In patients with ACS and cardiogenic shock, emergency revascularization of the culprit vessel is indicated; however, routine PCI of non-infarct-related arteries at the time of primary PCI is not recommended 1
• For patients requiring CABG after receiving antiplatelet therapy for ACS:
  • Clopidogrel should be stopped approximately 5 days before CABG 1, 5
  • For patients on prasugrel, discontinuation at least 7 days prior to CABG is recommended 5
• A multidisciplinary Heart Team approach is strongly recommended for revascularization decisions in complex cases, particularly for patients with diabetes and multivessel disease 1, 2

Antithrombotic Therapy Considerations

• Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor is recommended after ACS 2, 5
• A potent P2Y12 inhibitor (prasugrel or ticagrelor) is preferred over clopidogrel for ACS patients undergoing PCI 2, 5
• DAPT is typically recommended for 12 months after ACS with stent implantation 2, 5
• For patients requiring urgent CABG after PCI, the risk of significant bleeding must be balanced against the risk of stent thrombosis 5

Post-Revascularization Management

• Secondary prevention measures should be initiated after revascularization, including:
  • Antiplatelet therapy 2
  • Statins to achieve LDL cholesterol targets 2
  • Beta-blockers 2
  • ACE inhibitors or ARBs as appropriate 2
• Cardiac rehabilitation is recommended to improve outcomes 2

Common Pitfalls to Avoid

• Delaying revascularization in high-risk ACS patients 1
• Performing routine coronary revascularization in patients with non-left main CAD before non-cardiac surgery (not recommended) 1
• Failing to involve a multidisciplinary Heart Team for complex revascularization decisions 1
• Inadequate consideration of bleeding risk when timing CABG after antiplatelet therapy initiation 5
• Performing routine PCI of non-culprit arteries in patients with cardiogenic shock 1