Indications for CABG

• CABG is performed for both symptomatic and prognostic reasons

• Indications for CABG have been classified by the ACC& AHA according to the level of evidence supporting the usefulness and efficacy of the procedure• Class I - Conditions for which there is evidence and/or general

agreement that a given procedure or treatment is useful and effective• Class II - Conditions for which there is conflicting evidence and/or a

divergence of opinion about the usefulness or efficacy of a procedure or treatment• Class IIa - Weight of evidence or opinion is in favor of usefulness or

efficacy• Class IIb - Usefulness or efficacy is less well established by

evidence or opinion• Class III - Conditions for which there is evidence and/or general

agreement that the procedure/treatment is not useful or effective, and in some cases it may be harmful

IndicationAsymptomatic or Mild Angina

Stable Angina

Unstable Angina/ NSTEMI

Poor LV Function

Left main stenosis >50%

Class I Class I Class I Class I

Stenosis of proximal LAD and proximal circumflex >70%

Class I Class I Class I Class I

3-vessel disease Class I Class I  

Class I, with

proximal LAD

stenosis

2-vessel disease  

Class I if there is large area of viable myocardium in high-risk area

Class IIa if there is moderate viable area and ischemia

Class IIb  

IndicationAsymptomatic or Mild Angina

Stable Angina

Unstable Angina/ NSTEMI

Poor LV Function

With >70% proximal LAD stenosis

Class IIa

Class I with either

ejection fraction <

50% or demonstrable ischemia on noninvasive

testing

Class IIa Class I

Involving proximal LAD Class IIb      

1-vessel disease  

Class I if there is large area of viable myocardium in high-risk area

Class IIa, if there is viable moderate area and ischemia

Class IIb  

IndicationAsymptomatic or Mild Angina

Stable Angina

Unstable Angina/ NSTEMI

Poor LV Function

With >70% proximal LAD stenosis

Class IIa Class IIa Class IIa  

Involving proximal LAD Class IIb    

Other indications for CABG• Disabling angina (Class I)• Ongoing ischemia in the setting of a non-

ST segment elevation myocardial infarction that is unresponsive to medical therapy (Class I)• Poor left ventricular function but with

viable, nonfunctioning myocardium above the anatomical defect that can be revascularized

• CABG may be performed as an emergency procedure in the context of a STEMI in cases where it has not been possible to perform PCI or where this procedure has failed and there is persistent pain and ischemia threatening a significant area of myocardium despite medical therapy

CABG in STEMI

Other indications for CABG in the setting of STEMI are:• ventricular septal defect related to

myocardial infarction• papillary muscle rupture• free wall rupture• ventricular pseudoaneurysm• life-threatening ventricular arrhythmias,

and • cardiogenic shock

References• [Guideline] Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges

CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011 Nov 7.[Medline]

• Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004 Aug 31. 110(9):1168-76. [Medline]

• http://emedicine.medscape.com/article/1893992-overview#a3