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A New Guide for Revascularizing Patients With CAD

In the December 6, 2011 Journal of the American College of Cardiology, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) published guidelines on the management of patients undergoing CABG, one of the most common operations performed in the United States. These guidelines were released at the same time that the ACCF and AHA published recommendations for PCI. According to L. David Hillis, MD, FACP, chair of the ACCF/AHA guidelines committee for CABG, the landscape regarding when surgeons should perform CABG or PCI has been continually changing, particularly in the past 5 to 10 years. “Several recent investigations have shown that PCI and CABG have comparable outcomes when used in patients with certain coronary arterial anatomic features,” he says. “The last guidelines were published in 2004, but clinical trials have continued to improve our understanding of how to optimize the management of patients with coronary artery disease (CAD).” A Collaborative Approach to Determine Revascularization Through a collaboration of two writing committees, the ACCF/AHA guideline update contains the most extensive examination of CABG and PCI use for coronary revascularization. “While one committee was re-writing the CABG guidelines, a separate committee was revising the PCI guidelines,” explains Dr. Hillis. “Our goal was then to develop a consensus between cardiologists and surgeons over patient selection for these two procedures. Busy practitioners have historically been challenged when deciding on which patients should undergo revascularization rather than being treated medically, and whether revascularization should be accomplished with CABG or PCI.” Dr. Hillis says a section of the guidelines has been established to address questions that clinicians may have when deciding...

Examining the Neurologic & Cognitive Effects of CABG

Although the mortality rate associated with CABG has been declining, research suggests that patients who undergo these procedures are increasingly older and sicker. Risk factors for complications after CABG are high, and adverse neurologic outcomes (eg, stroke and cognitive decline) remain a major concern. Efforts to reduce post-CABG-related neurologic events have been hindered by an incomplete understanding of the pathophysiology of these events. One of the justifications for developing off-pump CABG was the hope that rates of embolization, and therefore stroke, would be lower than those experienced with on-pump surgery. However, a number of large prospective ran­domized trials have failed to show a significant difference in rates of post-surgical stroke between on- and off-pump bypass. In light of these findings, strategies to reduce the incidence of adverse post-CABG neurologic and cognitive outcomes should focus more on patient-related risk factors rather than procedure-specific outcomes. (see also, Revised Guidelines for Evidence-Based PCI) Changing Perceptions on CABG & Cognitive Decline In the January 19, 2012 New England Journal of Medicine, my colleagues and I published a review article on neuro­cognitive outcomes following CABG. Studies in the past have suggested that CABG causes cognitive decline. For example, a Duke University study published about 10 years ago suggested a high rate of cognitive decline at 5 years after CABG. But this study was not randomized and had no control groups. In a more recent study (although not randomized), my colleagues at Johns Hopkins compared cognitive outcomes over 6 years in patients undergoing CABG, a group with the same vascular risk factors that did not undergo surgery, and a group of heart-healthy con­trols. Although those...
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