Coronary Revascularization Quiz for Surgeons Based on 2021 ACC/AHA/SCAI Guidelines
Question 1: Heart Team Approach and Decision-Making
A 68-year-old patient with diabetes presents with multivessel coronary artery disease. The optimal revascularization strategy is unclear. According to the 2021 ACC/AHA/SCAI guidelines, what is the recommended approach?
A) Proceed directly to CABG based on diabetes diagnosis
B) Utilize a multidisciplinary Heart Team approach with shared decision-making
C) Default to PCI as first-line therapy
D) Defer revascularization and optimize medical therapy alone
Correct Answer: B
Explanation: The 2021 ACC/AHA/SCAI guidelines provide a Class I recommendation for a multidisciplinary Heart Team approach when the optimal treatment strategy is unclear 1. Treatment decisions must be patient-centered, incorporate patient preferences and goals, and include shared decision-making 1. This is particularly critical in patients with diabetes and multivessel disease, where revascularization decisions are optimized through Heart Team discussion 1, 2.
Question 2: Conduit Selection in CABG
During CABG planning for a patient requiring bypass of the LAD and a second target vessel with significant stenosis, which conduit should be preferred for the second most important target vessel after the LAD?
A) Saphenous vein graft
B) Radial artery graft
C) Internal mammary artery
D) Either saphenous vein or radial artery equally
Correct Answer: B
Explanation: The radial artery as a surgical revascularization conduit is preferred over saphenous vein graft to bypass the second most important target vessel with significant stenosis after the LAD 1. The benefits include superior patency, reduced adverse cardiac events, and improved survival compared to saphenous vein conduits 1. This represents a significant update in the 2021 guidelines emphasizing arterial grafting for improved long-term outcomes 1.
Question 3: Left Main Disease Management
A 72-year-old patient presents with significant left main coronary artery disease with low-to-medium anatomic complexity (SYNTAX score 18). What does the 2021 guideline recommend regarding revascularization to improve survival?
A) Medical therapy is equivalent to revascularization
B) Surgical revascularization is indicated; PCI is contraindicated
C) Surgical revascularization is indicated; PCI is a reasonable alternative in this patient
D) PCI is preferred over CABG for all left main disease
Correct Answer: C
Explanation: For patients with significant left main disease, surgical revascularization is indicated to improve survival relative to medical therapy 1. However, percutaneous revascularization is a reasonable option to improve survival compared with medical therapy in selected patients with low-to-medium anatomic complexity of CAD and left main disease that is equally suitable for surgical or percutaneous revascularization 1. The decision requires consideration of anatomic complexity and suitability for either approach 1.
Question 4: Diabetic Patients with Triple-Vessel Disease
A 65-year-old patient with diabetes mellitus and triple-vessel coronary artery disease is being evaluated for revascularization. According to the guidelines, what is the preferred revascularization strategy?
A) PCI with drug-eluting stents
B) Medical therapy alone
C) Surgical revascularization (CABG)
D) Staged hybrid revascularization
Correct Answer: C
Explanation: Patients with diabetes who have triple-vessel disease should undergo surgical revascularization 1. PCI may be considered only if they are poor candidates for surgery 1, 2. Revascularization decisions in patients with diabetes and multivessel CAD are optimized by the use of a Heart Team approach 1. This recommendation is based on superior long-term outcomes with CABG in this high-risk population 2.
Question 5: Risk Assessment for Surgical Revascularization
When evaluating a patient for CABG, which risk assessment tool should be calculated according to the 2021 guidelines to guide treatment decisions?
A) SYNTAX score alone
B) Society of Thoracic Surgeons (STS) score
C) EuroSCORE II
D) Framingham Risk Score
Correct Answer: B
Explanation: Treatment decisions for patients undergoing surgical revascularization of CAD should include the calculation of the Society of Thoracic Surgeons (STS) score 1, 2. The STS score is preferred over the SYNTAX score for surgical risk assessment because it includes clinical variables in addition to anatomic complexity 2. The SYNTAX score calculation may be useful in treatment decisions but is secondary to the STS score for surgical risk stratification 1. This comprehensive risk assessment helps guide appropriate patient selection for CABG versus alternative strategies 1.