Four cardiac surgery societies have endorsed recommendations of the European Society of Cardiology’s (ESC) 2024 chronic coronary syndromes (CCS) guidelines relating to coronary revascularisation.
The American Association for Thoracic Surgery (AATS), Society of Thoracic Surgeons (STS), Latin American Association of Cardiac and Endovascular Surgery (LACES) and Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS) this week released a multi-society paper, published simultaneously in a number of cardiac surgery journals, endorsing the statements from ESC.
ESC’s guidelines were published in August 2024, and among a series of broad recommendations include a review of the indications for and selection of the optimal revascularisation modality based on findings from large randomised controlled trials and individual patient data analyses.
Guidelines for coronary artery revascularisation have previously been a flashpoint between the cardiac surgery and interventional cardiology communities.
In 2022, AATS and STS opted not to endorse joint guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA) and the Society for Cardiovascular Angiography and Interventions (SCAI), which had downgraded recommendations for coronary artery bypass grafting (CABG) in patients with stable three-vessel coronary artery disease, preserved left ventricular function and no left main coronary artery stenosis.
The latest ESC guidelines state that in CCS patients with left ventricular ejection fraction >35%, myocardial revascularisation is recommended, “in addition to guideline-directed medical therapy, for patients with functionally significant three-vessel disease to improve long-term cardiovascular mortality and the risk of spontaneous myocardial infarction”, which carries a class I recommendation with a level of evidence A.
CABG and optimal medical therapy are recommended over both percutaneous coronary intervention (PCI) and optimal medical therapy alone in patients with diabetes, whilst in non-diabetic patients, CABG is recommended over optimal medical therapy alone to improve survival, symptoms and major cardiovascular events.
PCI is recommended alongside CABG in patients with intermediate or low coronary complexity if similar completeness in revascularisation can be achieved. The guidelines also recommend that when PCI and CABG have equal weighting, a heart team discussion is needed, and ad hoc PCI should not be performed.
“Until new evidence changes our current assessment, the surgical societies represented in this statement support the recommendations of the 2024 ESC guidelines for the management of chronic coronary syndromes,” the statement published in the European Journal of Cardio-Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery reads. “The consensus is that in patients with complex, three-vessel coronary artery disease on optimal medical therapy, CABG is recommended to improve survival and decrease major adverse cardiovascular events and symptoms (compared with optimal medical therapy alone or PCI), irrespective of left ventricular ejection fraction.
“The patient risk profile, heart team discussions, and informed patient preferences are all important qualifiers in the decision-making process.”
The statement concludes that the societies “remain committed to future collaboration with our colleagues from various disciplines for the benefit of our patients and the betterment of our field”.
