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## Complete Summary

#### GUIDELINE TITLE

ACC/AHA 2004 guideline update for coronary artery bypass graft surgery:
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).

#### BIBLIOGRAPHIC SOURCE(S)

Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart
JC, Herrmann HC, Hillis LD, Hutter AM Jr, Lytle BW, Marlow RA, Nugent
WC, Orszulak TA. ACC/AHA 2004 guideline update for coronary artery
bypass graft surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines.
Bethesda (MD): American College of Cardiology; 2004. 99 p. \[795
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of
Cardiology, American Heart Association, Eagle KA, Guyton RA, Davidoff R,
Ewy GA, Fonger J, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O\'Connor
GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert
JS, Eagle KA, Garson A Jr, Gregoratos G, Russell RO, Smith SC Jr.
ACC/AHA Guidelines for coronary artery bypass graft surgery. J Am Coll
Cardiol 1999 Oct;34(4):1262-347.

This document will be reviewed one year after the date of publication
and yearly thereafter by the Task Force to determine whether a revision
is needed. The guidelines will be considered current, unless the Task
Force publishes revisions or a withdrawal.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [August 16, 2007, Coumadin
    (Warfarin)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Warfarin):
    Updates to the labeling for Coumadin to include pharmacogenomics
    information to explain that people\'s genetic makeup may influence
    how they respond to the drug.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [October 6, 2006, Coumadin (warfarin
    sodium)](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Coumadin):
    Revisions to the labeling for Coumadin to include a new patient
    Medication Guide as well as a reorganization and highlighting of the
    current safety information to better inform providers and patients.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Coronary artery diseases (CAD) including asymptomatic or mild angina,
stable angina, unstable angina/non-ST-segment elevation myocardial
infarction (MI), ST-segment elevation myocardial infarction (STEMI),
poor left ventricular (LV) function, and life-threatening ventricular
arrhythmias

#### GUIDELINE CATEGORY

Prevention\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To assist physicians in clinical decision making by presenting
recommendations regarding the appropriate use of coronary artery bypass
graft (CABG) surgery

#### TARGET POPULATION

Adults with coronary artery disease

**Note**: Special patient subsets include the elderly
([\>]{.underline}70 years); women; patients with diabetes; patients with
pulmonary disease, chronic obstructive pulmonary disease (COPD), or
respiratory insufficiency; patients with end-stage renal disease;
patients with valve disease; patients with a prior history of coronary
artery bypass graft (CABG); patients with concomitant peripheral
vascular disease (PVD); patients with poor left ventricular (LV)
function; transplantation patients; and patients with acute coronary
syndromes.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation/Risk Assessment**

1.  Echocardiography

2.  Carotid screening (carotid duplex ultrasound)

3.  Left ventricular (LV) function

4.  Ejection fraction (EF)

5.  Assessment of cardiac biomarkers including creatine kinase-muscle
    band (CK-MB) and troponin T

**Management/Treatment**

1.  Coronary artery bypass graft (CABG) surgery

2.  Medical therapy (preoperative and postoperative) including:

    -   Beta-blockers

    -   Nitrates

    -   Calcium channel blockers (Note: nondihydropyridine calcium
        channel blockers are not recommended for prophylaxis of
        arrhythmias though they are useful for control of ventricular
        rate)

    -   Anti-arrhythmic agents (e.g., sotalol, amiodarone)

    -   Anticoagulants (warfarin, aspirin)

    -   Lipid-lowering agents (e.g., statins)

    -   Angiotensin-converting enzyme inhibitors

    -   Digoxin (not recommended for prophylaxis of arrhythmias though
        useful for control of ventricular rate)

    -   Prophylactic antibiotic administration (e.g., cephalosporins
        such as cefuroxime, cefamandole, or cefazolin; vancomycin for
        penicillin allergic)

    -   Hormone therapy (not recommended)

3.  Percutaneous coronary intervention (PCI)

4.  Transmyocardial surgical laser revascularization

5.  Carotid endarterectomy

6.  Aortic valve replacement

7.  Prophylactic intra-aortic balloon pump

8.  Smoking cessation therapy (nicotine replacement and bupropion)

9.  Cardiac rehabilitation

#### MAJOR OUTCOMES CONSIDERED

-   Relief of symptoms of angina

-   Morbidity and mortality including:

    -   Long-term survival after bypass surgery (total mortality at 5
        and 10 years)

    -   Hospital mortality

    -   Adverse cerebral outcomes

    -   Mediastinitis

    -   Renal dysfunction

-   Predictive value of tests

-   Quality of life

-   Length of hospitalization

-   Incidence of myocardial infarction (MI) including ST segment
    elevation

-   Incidence of perioperative stroke

-   Incidence of neurological injury

-   Incidence of perioperative myocardial dysfunction

-   Repeat revascularization rates

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Committee reviewed pertinent publications, including abstracts,
through a computerized search of the English literature since 1999 and
performed a manual search of final articles. Special attention was
devoted to identification of randomized trials published since the
original document.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Level of Evidence**

**Level of Evidence A**: Data derived from multiple randomized clinical
trials or meta-analyses\
**Level of Evidence B**: Data derived from a single randomized trial, or
nonrandomized studies\
**Level of Evidence C**: Only consensus opinion of experts, case
studies, or standard-of-care

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

A complete listing of all publications covering coronary bypass surgery
in the past 4 years is beyond the scope of this document. However,
evidence tables were updated to reflect major advances over this time
period. Inaccuracies or inconsistencies present in the original
publication were identified and corrected when possible.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Balance Sheets\
Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Experts in the subject under consideration are selected from the
American College of Cardiology and the American Heart Association to
examine subject-specific data and write guidelines. The process includes
additional representatives from other medical specialty groups when
appropriate. Writing groups are specifically charged to perform a formal
literature review, weigh the strength of evidence for or against a
particular treatment or procedure, and include estimates of expected
health outcomes where data exist. Patient-specific modifiers,
comorbidities, and issues of patient preference that might influence the
choice of particular tests or therapies are considered as well as
frequency of follow-up and cost-effectiveness.

Since the initial guidelines for coronary artery bypass graft (CABG)
surgery were published in 1991, there has been additional evolution in
the surgical approach to coronary disease while at the same time there
have been significant advances in preventive, medical, and percutaneous
catheter approaches to therapy.

The current Writing Committee was charged with updating the guidelines
published in 1999.All of the recommendations in this guideline update
have been written in full sentences that express a complete thought,
such that a recommendation, even if separated and presented apart from
the rest of the document, would still convey the full intent of the
recommendation. It is hoped that this will increase readers\'
comprehension of the guidelines. Also, the level of evidence, either A,
B, or C, for each recommendation (see \"Rating Scheme for the Strength
of the Evidence\" above), is now provided.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Class I**: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is beneficial, 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/opinion is in favor of
usefulness/efficacy.

**Class IIb**: Usefulness/efficacy is less well established by
evidence/opinion.

**Class III**: Conditions for which there is evidence and/or general
agreement that a procedure/treatment is not useful/effective and in some
cases may be harmful.

#### COST ANALYSIS

**Cardiac Rehabilitation**

In addition to benefiting a sense of well-being, there is an economic
benefit that accrues from participation in cardiac rehabilitation
programs. During a 3-year follow-up (mean of 21 months) after coronary
events (58% of events were coronary bypass operations), per capita
hospitalization charges were \$739 lower for rehabilitated patients
compared with nonparticipants (\$1,197 [+]{.underline} 3,911 versus
\$1,936 [+]{.underline} 5,459, *P* = 0.022).

**Coronary Artery Bypass Graft (CABG)**

***Cost-Effectiveness of CABG***\
CABG represents a major investment for society, with an initial hospital
cost of around \$30,000 applied to more than 300,000 patients annually
in the United States alone (around 10 billion dollars). It is most
appropriate to consider the cost of CABG surgery compared with other
medical treatment modalities with regard to cost-effectiveness.
Definitive data for such a comparison are sparse, and multiple
assumptions must be made. The most reasonable system of analysis appears
to be an estimation of the dollars spent per quality-adjusted life-year
gained (\$/QALY). In general, a cost-effectiveness of \$20,000 to
\$40,000/QALY is consistent with other medical programs funded by
society, such as hemodialysis and treatment of hypertension. A cost of
under \$20,000/QALY would be considered particularly cost-effective,
while a cost greater than \$60,000/QALY would be considered expensive.
(Note: The dollar amounts given here are in 1993 dollars).

A widely quoted analysis of the cost-effectiveness of CABG surgery was
compiled in 1982 utilizing data gathered from the then available
randomized trials comparing medical therapy with coronary artery bypass.
The cost of coronary bypass is relatively constant, whether it is
conducted for left main disease or for single-vessel disease.

Cost-effectiveness is excellent when the procedure is applied to patient
subgroups for whom the benefit in terms of survival or relief of
symptoms compared with medical therapy is great (as it would be, for
example, in a patient with severe angina and triple-vessel disease). The
cost-effectiveness of CABG becomes inordinately poor, however, when the
benefit in terms of survival is marginal and there are few symptoms in
the preoperative patient. These conclusions are depicted in Figure 12 in
the original guideline document, and examples are presented in Table 18
in the original guideline document. Cost-effectiveness for coronary
bypass in patients with left main disease is exceptionally good at
\$9,000/QALY. It is similarly quite attractive in patients with 3-vessel
disease, at \$18,000/QALY. If one considers the cost-effectiveness of
coronary bypass in 2-vessel disease, one study found that the presence
or absence of left anterior descending (LAD) disease was very important.
Because CABG surgery is particularly effective in relieving angina, its
cost-effectiveness, even in patients with single-vessel disease, is not
prohibitive if that patient has severe angina. In the patient without
angina or with only mild angina, however, the cost of coronary bypass
per QALY was prohibitive in this analysis, exceeding \$100,000 for
patients with 2-vessel or 1-vessel disease.

It is not surprising that coronary bypass surgery is cost-effective in
exactly those groups of patients in whom survival and/or symptomatic
benefit is demonstrable. Most important, within these subsets the
cost-effectiveness of coronary bypass compares favorably with other
generally accepted medical therapies.

***Cost Comparison With Angioplasty***\
The cost-effectiveness of angioplasty is dependent on the
pre-angioplasty symptoms of the patient in the same way that CABG
surgery is so dependent, particularly in subgroups in whom
revascularization cannot be shown to have a survival benefit compared
with medical therapy (i.e., in single-vessel disease). Because it
relieves angina, angioplasty for single-vessel-disease patients with
severe angina is estimated to have a cost-effectiveness of \$9,000/QALY.
In patients with only mild angina, however, angioplasty in the setting
of LAD single-vessel disease is estimated to have a poor
cost-effectiveness of \$92,000/QALY.

A direct comparison of the cost of angioplasty and coronary bypass
surgery for selected patients with multivessel disease (i.e., those
patients for whom either therapeutic modality was considered
appropriate) has been made in the randomized trials of angioplasty
versus CABG. In general, the cost analyses of randomized trials have
revealed that the initial cost of angioplasty is about 50 to 65% of the
initial cost of bypass surgery. The incremental cost of repeated
procedures during the follow-up period has led to a cumulative cost of
angioplasty that approaches the cumulative cost of bypass surgery at 3
years. The Emory Angioplasty versus Surgery Trial (EAST) found that the
3-year inpatient cost of angioplasty was 94% of that of bypass surgery.
The Randomized Intervention Treatment of Angina (RITA) Trial, which
included a large number of patients with single-vessel disease, found
that the 2-year cumulative cost of angioplasty was 80% of the cost of
coronary bypass. The Bypass Angioplasty Revascularization Investigation
(BARI) trial conducted a prospectively designed analysis of the
comparative cost of the 2 procedures from a subgroup of the
participating centers, comprising a total of 934 of the 1,829 patients
enrolled. The mean initial hospital cost of angioplasty was 65% of that
of surgery, but after 5 years the cumulative cost of initial surgical
therapy was only \$2,700 more than the cumulative cost of initial
angioplasty (around a 5% difference). Because the surgical cohort had a
higher overall 5-year survival, the cost of this survival benefit could
be calculated. It was found to be \$26,000/y of survival benefit for
surgical therapy of 2-and 3-vessel disease (in patients for whom either
angioplasty or surgery was considered appropriate initial therapy). As
considered in the previous section, this incremental cost for double-
and triple-vessel disease is within the range of costs for generally
accepted therapies. It is notable that this cost of incremental benefit
does not consider the benefit of coronary bypass in terms of relief of
angina during the follow-up interval, which was demonstrated in each of
these 3 trials (Bypass Angioplasty Revascularization Investigation,
Emory Angioplasty versus Surgery Trial, and Randomized Intervention
Treatment of Angina). If this factor were included, the
*cost-effectiveness* of CABG for incremental benefit in these selected
patients with multivessel disease (\$/QALY) would be \<\$26,000.

Previous considerations of both patient benefit and cost-effectiveness
have suggested that angioplasty is less effective for patients with more
advanced disease. Data gathered at Duke University has shown that there
is a significant cost gradient for angioplasty as the extent of disease
increases (related to repeated procedures whose instance may be reduced
by stents), which is not apparent for coronary bypass.

The use of drug-eluting stents in percutaneous revascularization will
require a re-evaluation of cost-effectiveness considerations. The
initial procedure is considerably more expensive (equaling the cost of
CABG in many patients with multivessel disease), but the recurring cost
of reintervention for restenosis will be dramatically reduced.
Cost-effectiveness will depend on pricing of stents, utilization rates
of the more expensive stents, and efficacy. All of these factors are
evolving rapidly.

***Cost Reduction in Coronary Bypass***\
Estimates presented in the previous portion of this section suggest that
coronary bypass has been cost-effective in the last 2 decades.
Initiatives to decrease the length of stay by using clinical pathways
and standardized fast-track protocols have reduced hospital costs.
Indeed, the estimates made by Weinstein and Stason are distinctly dated:
improvements in outcomes and shortened lengths of hospitalization are
likely to have considerably improved the cost-effectiveness of CABG (and
angioplasty) since 1982.

Studies from the 1980s suggested that by concentrating CABG procedures
into high-volume institutions, the overall cost of providing coronary
surgical revascularization would be reduced owing to efficiencies of
scale. Shahian et al studied this question and found no relationship
between either hospital size or annual CABG case volume and cost of
performing bypass surgery.

A major innovation has been the introduction of off-bypass CABG, which
has reduced the postprocedure length of stay in some centers to between
2 and 3 days. In some centers, this has led to a total 3-month cost for
single-vessel coronary bypass that is not significantly different from
the total 3-month cost for angioplasty of single-vessel disease.
Considering the favorable long-term patency of an internal mammary
artery (IMA) graft to the LAD, the cost reductions possible with
off-bypass CABG may improve the relative cost-effectiveness of coronary
bypass compared with either medical therapy or percutaneous techniques,
particularly for symptomatic, proximal LAD disease.

#### METHOD OF GUIDELINE VALIDATION

Comparison with Guidelines from Other Groups\
External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The original guideline document was reviewed by 3 outside observers
nominated by the American College of Cardiology (ACC), 3 outside
reviewers nominated by the American Heart Association (AHA), one content
reviewer from the Task Force on Practice Guidelines, and outside
reviewers nominated by the Society of Thoracic Surgeons (STS) and the
Society of Cardiovascular Anesthesiologists.

The ACC/AHA 2004 Guideline Update for Coronary Artery Bypass graft
(CABG) was approved for publication by the ACC Foundation (ACCF) Board
of Trustees in March 2004 and the AHA Science and Advisory Coordinating
Committee in June 2004, and was endorsed by the American Association for
Thoracic Surgery and the STS.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*Note from the National Guideline Clearinghouse (NGC)*: The
recommendations listed below are from the Summary Article (see
\"Companion Documents\" field). Readers are referred to the full-text
original guideline document for context.

Levels of evidence (A-C) and classes of recommendations (I, IIa, IIb,
and III) are defined at the end of the \"Major Recommendations\" field.

**Outcomes**

**Hospital Outcomes**

*Predicting Hospital Mortality*

*Class IIa*

1.  It is reasonable to use statistical risk models to obtain objective
    estimates of coronary artery bypass graft (CABG) operative
    mortality. *(Level of Evidence: C)*

*Morbidity Associated with CABG: Adverse Cerebral Outcomes*

*Class I*

1.  Significant atherosclerosis of the ascending aorta mandates a
    surgical approach that will minimize the possibility of
    arteriosclerotic emboli. *(Level of Evidence: C)*

**Management Strategies**

**Reduction of Perioperative Mortality and Morbidity**

*Reducing the Risk of Brain Dysfunction After CABG*

[Atrial Fibrillation and Postoperative Stroke]{.underline}

*Class IIa*

1.  In post-CABG atrial fibrillation that is recurrent or persists more
    than 24 hours, warfarin anticoagulation for 4 weeks is probably
    indicated. *(Level of Evidence: C)*

[Recent Anterior Myocardial Infarction (MI), Left Ventricular (LV) Mural
Thrombus, and Stroke Risk]{.underline}

*Class IIa*

1.  Long-term (3 to 6 months) anticoagulation is probably indicated for
    the patient with recent anteroapical infarct and persistent
    wall-motion abnormality after CABG. *(Level of Evidence: C)*

*Class IIb*

1.  In patients having a recent anterior MI, preoperative screening with
    echocardiography may be considered to detect left ventricular (LV)
    thrombus, because the technical approach and timing of surgery may
    be altered. *(Level of Evidence: C)*

[Carotid Disease and Neurological Risk Reduction]{.underline}

*Class IIa*

1.  Carotid endarterectomy is probably recommended before CABG or
    concomitant to CABG in patients with a symptomatic carotid stenosis
    or in asymptomatic patients with a unilateral or bilateral internal
    carotid stenosis of 80% or more. (*Level of Evidence: C)*

2.  Carotid screening is probably indicated in the following subsets:
    age greater than 65 years, left main coronary stenosis, peripheral
    vascular disease, history of smoking, history of transient ischemic
    attack or stroke, or carotid bruit on examination. *(Level of
    Evidence: C)*

*Reducing the Risk of Perioperative Myocardial Dysfunction*

[Myocardial Protection for Acutely Depressed Cardiac
Function]{.underline}

*Class I*

1.  Blood cardioplegia should be considered in patients undergoing
    cardiopulmonary bypass accompanying urgent/emergency CABG for acute
    MI or unstable angina. *(Level of Evidence: B)*

[Protection for Chronically Dysfunctional Myocardium]{.underline}

*Class IIa*

1.  Blood cardioplegia is probably indicated in patients undergoing
    cardiopulmonary bypass accompanying CABG in the presence of a
    chronically dysfunctional left ventricle. *(Level of Evidence: B)*

[Cardiac Biomarker Elevation and Outcome]{.underline}

*Class IIb*

1.  Assessment of cardiac biomarkers in the first 24 hours after CABG
    may be considered, and patients with the highest elevations of
    creatine kinase-muscle band (MB) (greater than 5 times upper limits
    of normal) are at increased risk of subsequent events. *(Level of
    Evidence: B)*

[Adjuncts to Myocardial Protection]{.underline}

*Class IIa*

1.  The use of a prophylactic intra-aortic balloon pump (IABP) as an
    adjunct to myocardial protection is probably indicated in patients
    with evidence of ongoing myocardial ischemia and/or patients with a
    subnormal cardiac index. *(Level of Evidence: B)*

[Inferior Infarct with Right Ventricular Involvement]{.underline}

*Class IIa*

1.  After infarction that leads to clinically significant right
    ventricular dysfunction, it is reasonable to delay surgery for 4
    weeks to allow recovery. *(Level of Evidence: C)*

*Reducing the Risk of Perioperative Infection*

*Class I*

1.  Preoperative antibiotic administration should be used in all
    patients to reduce the risk of postoperative infection. *(Level of
    Evidence: A)*

2.  In the absence of complicating circumstances, a deep sternal wound
    infection should be treated with aggressive surgical debridement and
    early revascularized muscle flap coverage. *(Level of Evidence: B)*

*Class IIa*

1.  The risk for deep sternal wound infection is reduced by aggressive
    control of perioperative hyperglycemia by using a continuous,
    intravenous insulin infusion. (Furnary et al., 1999) *(Level of
    Evidence: B)*

*Prevention of Postoperative Arrhythmias*

*Class I*

1.  Preoperative or early postoperative administration of beta-blockers
    in patients without contraindications should be used as the standard
    therapy to reduce the incidence and/or clinical sequelae of atrial
    fibrillation after CABG. *(Level of Evidence: B)*

*Class IIa*

1.  Preoperative administration of amiodarone reduces the incidence of
    postcardiotomy atrial fibrillation and is an appropriate
    prophylactic therapy for patients at high risk for postoperative
    atrial fibrillation who have contraindications to therapy with
    beta-blockers. *(Level of Evidence: B)*

2.  Digoxin and nondihydropyridine calcium-channel blockers are useful
    for control of ventricular rate but at present have no indication
    for prophylaxis. *(Level of Evidence: B)*

*Class IIb*

1.  Low-dose sotalol can be considered to reduce the incidence of atrial
    fibrillation after CABG in patients who are not candidates for
    traditional beta-blockers. *(Level of Evidence: B)*

**Maximizing Postoperative Benefit**

*Antiplatelet Therapy for Saphenous Vein Graft (SVG) Patency*

*Class I*

1.  Aspirin is the drug of choice for prophylaxis against early
    saphenous vein graft closure. It is the standard of care and should
    be continued indefinitely given its benefit in preventing subsequent
    clinical events. *(Level of Evidence: A)*

*Pharmacological Management of Hyperlipidemia*

*Class I*

1.  All patients undergoing CABG should receive statin therapy unless
    otherwise contraindicated. *(Level of Evidence: A)*

*Hormonal Manipulation*

*Class III*

1.  Initiation of hormone therapy is not recommended for women
    undergoing CABG surgery. *(Level of Evidence: B)*

*Smoking Cessation*

*Class I*

1.  All smokers should receive educational counseling and be offered
    smoking cessation therapy after CABG. *(Level of Evidence: B)*

2.  Pharmacological therapy including nicotine replacement and bupropion
    should be offered to select patients indicating a willingness to
    quit. *(Level of Evidence: B)*

*Cardiac Rehabilitation*

*Class I*

1.  Cardiac rehabilitation should be offered to all eligible patients
    after CABG. *(Level of Evidence: B)*

**Special Patient Subsets**

**Valve Disease**

*Class I*

1.  Patients undergoing CABG who have severe aortic stenosis (mean
    gradient greater than or equal to 50 mm Hg or Doppler velocity
    greater than or equal to 4 meters per second) who meet the criteria
    for valve replacement should have concomitant aortic valve
    replacement. *(Level of Evidence: B)*

*Class IIa*

1.  For a preoperative diagnosis of clinically significant mitral
    regurgitation concomitant mitral correction at the time of CABG is
    probably indicated. *(Level of Evidence: B)*

2.  In patients undergoing CABG who have moderate aortic stenosis and
    are at acceptable risk for aortic valve replacement (mean gradient
    30 to 50 mm Hg or Doppler velocity 3 to 4 meters per second),
    concomitant aortic valve replacement is probably indicated. *(Level
    of Evidence: B)*

*Class IIb*

1.  Patients undergoing CABG who have mild aortic stenosis (mean
    gradient less than 30 mm Hg or Doppler velocity less than 3 meters
    per second) may be considered candidates for aortic valve
    replacement if the risk of the combined procedure is acceptable.
    *(Level of Evidence: C)*

**CABG in Acute Coronary Syndromes**

*Class I*

1.  If clinical circumstances permit, clopidogrel should be withheld for
    5 days before the performance of CABG surgery. *(Level of Evidence:
    B)*

**Impact of Evolving Technology**

**Arterial and Alternate Conduits**

*Class I*

1.  In every patient undergoing CABG, the left internal mammary artery
    (IMA) should be given primary consideration for revascularization of
    the left anterior descending (LAD) artery. *(Level of Evidence: B)*

**Transmyocardial Laser Revascularization (TMLR) (refer to the TMR
section of the Stable Angina Update)**

*Class IIa*

1.  Transmyocardial surgical laser revascularization, either alone or in
    combination with CABG, is reasonable in patients with angina
    refractory to medical therapy who are not candidates for
    percutaneous coronary intervention (PCI) or surgical
    revascularization. *(Level of Evidence: A)*

**Indications**

**Clinical Subsets**

*Asymptomatic or Mild Angina*

*Class I*

1.  CABG should be performed in patients with no angina or mild angina
    who have significant left main coronary artery stenosis. *(Level of
    Evidence: A)*

2.  CABG should be performed in patients with no angina or mild angina
    who have left main equivalent: significant (greater than or equal to
    70%) stenosis of the proximal LAD and proximal left circumflex
    artery. *(Level of Evidence: A)*

3.  CABG is useful in patients with no angina or mild angina who have
    3-vessel disease. (Survival benefit is greater in patients with
    abnormal LV function; e.g., ejection fraction \[EF\] less than 0.50
    and/or large areas of demonstrable myocardial ischemia.) *(Level of
    Evidence: C)*

*Class IIa*

1.  CABG can be beneficial for patients with no angina or mild angina
    who have proximal LAD stenosis with 1- or 2-vessel disease. (This
    recommendation becomes Class I if extensive ischemia is documented
    by a noninvasive study and/or left ventricular ejection fraction
    (LVEF) is less than 0.50.) *(Level of Evidence: A)*

*Class IIb*

1.  CABG may be considered for patients with no angina or mild angina
    who have 1- or 2-vessel disease not involving the proximal LAD. (If
    a large area of viable myocardium and high-risk criteria are met on
    noninvasive testing, this recommendation becomes Class I). *(Level
    of Evidence: B)*

*Stable Angina*

*Class I*

1.  CABG is recommended for patients with stable angina who have
    significant left main coronary artery stenosis. *(Level of Evidence:
    A*)

2.  CABG is recommended for patients with stable angina who have left
    main equivalent: significant (greater than or equal to 70%) stenosis
    of the proximal LAD and proximal left circumflex artery. *(Level of
    Evidence: A)*

3.  CABG is recommended for patients with stable angina who have
    3-vessel disease. (Survival benefit is greater when LVEF is less
    than 0.50.) *(Level of Evidence: A)*

4.  CABG is recommended in patients with stable angina who have 2-vessel
    disease with significant proximal LAD stenosis and either EF less
    than 0.50 or demonstrable ischemia on noninvasive testing. *(Level
    of Evidence: A)*

5.  CABG is beneficial for patients with stable angina who have 1- or
    2-vessel coronary artery disease (CAD) without significant proximal
    LAD stenosis but with a large area of viable myocardium and
    high-risk criteria on noninvasive testing. *(Level of Evidence: B)*

6.  CABG is beneficial for patients with stable angina who have
    developed disabling angina despite maximal noninvasive therapy, when
    surgery can be performed with acceptable risk. If the angina is not
    typical, objective evidence of ischemia should be obtained. *(Level
    of Evidence: B)*

*Class IIa*

1.  CABG is reasonable in patients with stable angina who have proximal
    LAD stenosis with 1-vessel disease. (This recommendation becomes
    Class I if extensive ischemia is documented by noninvasive study
    and/or LVEF is less than 0.50.) *(Level of Evidence: A)*

2.  CABG may be useful for patients with stable angina who have 1- or
    2-vessel CAD without significant proximal LAD stenosis but who have
    a moderate area of viable myocardium and demonstrable ischemia on
    noninvasive testing. *(Level of Evidence: B)*

*Class III*

1.  CABG is not recommended for patients with stable angina who have 1-
    or 2-vessel disease not involving significant proximal LAD stenosis,
    patients who have mild symptoms that are unlikely due to myocardial
    ischemia, or patients who have not received an adequate trial of
    medical therapy and:

    a.  Have only a small area of viable myocardium *(Level of Evidence:
        B)* or

    b.  Have no demonstrable ischemia on noninvasive testing. *(Level of
        Evidence: B)*

2.  CABG is not recommended for patients with stable angina who have
    borderline coronary stenoses (50 to 60% diameter in locations other
    than the left main coronary artery) and no demonstrable ischemia on
    noninvasive testing. *(Level of Evidence: B)*

3.  CABG is not recommended for patients with stable angina who have
    insignificant coronary stenosis (less than 50% diameter reduction).
    *(Level of Evidence: B)*

*Unstable Angina/Non-ST-Segment Elevation Myocardial infarction (MI)*

*Class I*

1.  CABG should be performed for patients with unstable
    angina/non--ST-segment elevation MI with significant left main
    coronary artery stenosis. *(Level of Evidence: A)*

2.  CABG should be performed for patients with unstable
    angina/non--ST-segment elevation MI who have left main equivalent:
    significant (greater than or equal to 70%) stenosis of the proximal
    LAD and proximal left circumflex artery. *(Level of Evidence: A)*

3.  CABG is recommended for unstable angina/non--ST-segment elevation MI
    in patients in whom percutaneous revascularization is not optimal or
    possible, and who have ongoing ischemia not responsive to maximal
    nonsurgical therapy. *(Level of Evidence: B)*

*Class IIa*

1.  CABG is probably indicated in patients with unstable
    angina/non--ST-segment elevation MI who have proximal LAD stenosis
    with 1- or 2-vessel disease. *(Level of Evidence: A)*

*Class IIb*

1.  CABG may be considered in patients with unstable
    angina/non--ST-segment elevation MI who have 1- or 2-vessel disease
    not involving the proximal LAD when percutaneous revascularization
    is not optimal or possible. (If there is a large area of viable
    myocardium and high-risk criteria are met on noninvasive testing,
    this recommendation becomes Class I.) *(Level of Evidence: B)*

*ST-Segment Elevation MI (STEMI)*

*Class I*

1.  Emergency or urgent CABG in patients with STEMI should be undertaken
    in the following circumstances:

    a.  Failed angioplasty with persistent pain or hemodynamic
        instability in patients with coronary anatomy suitable for
        surgery. *(Level of Evidence: B)*

    b.  Persistent or recurrent ischemia refractory to medical therapy
        in patients who have coronary anatomy suitable for surgery, who
        have a significant area of myocardium at risk, and who are not
        candidates for percutaneous coronary intervention *(Level of
        Evidence: B)*

    c.  At the time of surgical repair of postinfarction ventricular
        septal rupture or mitral valve insufficiency. *(Level of
        Evidence: B)*

    d.  Cardiogenic shock in patients less than 75 years old with
        ST-segment elevation or left bundle-branch block or posterior MI
        who develop shock within 36 hours of MI and are suitable for
        revascularization that can be performed within 18 hours of
        shock, unless further support is futile because of the
        patient\'s wishes or contraindications/unsuitability for further
        invasive care. *(Level of Evidence: A)*

    e.  Life-threatening ventricular arrhythmias in the presence of
        greater than or equal to 50% left main stenosis and/or
        triple-vessel disease. *(Level of Evidence: B)*

*Class IIa*

1.  CABG may be performed as primary reperfusion in patients who have
    suitable anatomy and who are not candidates for or who have had
    failed fibrinolysis/PCI and who are in the early hours (6 to 12
    hours) of evolving STEMI *(Level of Evidence: B)*

2.  In patients who have had an ST-segment elevation MI or
    non--ST-segment elevation MI, CABG mortality is elevated for the
    first 3 to 7 days after infarction, and the benefit of
    revascularization must be balanced against this increased risk.
    Beyond 7 days after infarction, the criteria for revascularization
    described in previous sections are applicable. *(Level of Evidence:
    B)*

*Class III*

1.  Emergency CABG should not be performed in patients with persistent
    angina and a small area of myocardium at risk who are
    hemodynamically stable. *(Level of Evidence: C)*

2.  Emergency CABG should not be performed in patients with successful
    epicardial reperfusion but unsuccessful microvascular reperfusion.
    *(Level of Evidence: C)*

*Poor LV Function*

*Class I*

1.  CABG should be performed in patients with poor LV function who have
    significant left main coronary artery stenosis. *(Level of Evidence:
    B)*

2.  CABG should be performed in patients with poor LV function who have
    left main equivalent: significant (greater than or equal to 70%)
    stenosis of the proximal LAD and proximal left circumflex artery.
    *(Level of Evidence: B)*

3.  CABG should be performed in patients with poor LV function who have
    proximal LAD stenosis with 2- or 3-vessel disease. *(Level of
    Evidence: B)*

*Class IIa*

1.  CABG may be performed in patients with poor LV function with
    significant viable noncontracting, revascularizable myocardium and
    without any of the above anatomic patterns. *(Level of Evidence: B)*

*Class III*

1.  CABG should not be performed in patients with poor LV function
    without evidence of intermittent ischemia and without evidence of
    significant revascularizable viable myocardium. *(Level of Evidence:
    B)*

*Life-Threatening Ventricular Arrhythmias*

*Class I*

1.  CABG should be performed in patients with life-threatening
    ventricular arrhythmias caused by left main coronary artery
    stenosis. *(Level of Evidence: B)*

2.  CABG should be performed in patients with life-threatening
    ventricular arrhythmias caused by 3-vessel coronary disease. *(Level
    of Evidence: B)*

*Class IIa*

1.  CABG is reasonable in bypassable 1- or 2-vessel disease causing
    life-threatening ventricular arrhythmias. (This becomes a Class I
    recommendation if the arrhythmia is resuscitated sudden cardiac
    death or sustained ventricular tachycardia.) *(Level of Evidence:
    B)*

2.  CABG is reasonable in life-threatening ventricular arrhythmias
    caused by proximal LAD disease with 1- or 2-vessel disease. (This
    becomes a Class I recommendation if the arrhythmia is resuscitated
    sudden cardiac death or sustained ventricular tachycardia.) *(Level
    of Evidence: B)*

*Class III*

1.  CABG is not recommended in ventricular tachycardia with scar and no
    evidence of ischemia. *(Level of Evidence: B)*

*CABG After Failed Percutaneous Transluminal Coronary Angioplasty
(PTCA)*

*Class I*

1.  CABG should be performed after failed PTCA in the presence of
    ongoing ischemia or threatened occlusion with significant myocardium
    at risk. *(Level of Evidence: B)*

2.  CABG should be performed after failed PTCA for hemodynamic
    compromise. *(Level of Evidence: B)*

*Class IIa*

1.  It is reasonable to perform CABG after failed PTCA for a foreign
    body in crucial anatomic position. *(Level of Evidence: C)*

2.  CABG can be beneficial after failed PTCA for hemodynamic compromise
    in patients with impairment of the coagulation system and without
    previous sternotomy. *(Level of Evidence: C)*

*Class IIb*

1.  CABG can be considered after failed PTCA for hemodynamic compromise
    in patients with impairment of the coagulation system and with
    previous sternotomy. *(Level of Evidence: C)*

*Class III*

1.  CABG is not recommended after failed PTCA in the absence of
    ischemia. *(Level of Evidence: C)*

2.  CABG is not recommended after failed PTCA with inability to
    revascularize due to target anatomy or no-reflow state. *(Level of
    Evidence: C)*

*Patients With Previous CABG*

*Class I*

1.  Coronary bypass should be performed in patients with prior CABG for
    disabling angina despite optimal nonsurgical therapy. (If angina is
    not typical, then objective evidence of ischemia should be
    obtained.) *(Level of Evidence: B)*

2.  Coronary bypass should be performed in patients with prior CABG
    without patent bypass grafts but with Class I indications for
    surgery for native-vessel coronary artery disease (significant left
    main coronary stenosis, left main equivalent, 3-vessel disease).
    *(Level of Evidence: B)*

*Class IIa*

1.  Coronary bypass is reasonable in patients with prior CABG and
    bypassable distal vessel(s) with a large area of threatened
    myocardium by noninvasive studies. *(Level of Evidence: B)*

2.  Coronary bypass is reasonable in patients with prior CABG if
    atherosclerotic vein grafts with stenoses greater than 50% supplying
    the LAD coronary artery or large areas of myocardium are present.
    *(Level of Evidence: B)*

**Definitions**:

**Levels of Evidence**

**Level of Evidence A**: Data derived from multiple randomized clinical
trials or meta-analyses\
**Level of Evidence B**: Data derived from a single randomized trial, or
nonrandomized studies\
**Level of Evidence C**: Only consensus opinion of experts, case
studies, or standard-of-care

**Classes of Recommendations**

**Class I**: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is beneficial, 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/opinion is in favor of
usefulness/efficacy.

**Class IIb**: Usefulness/efficacy is less well established by
evidence/opinion.

**Class III**: Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful/effective and in
some cases may be harmful.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=5582)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation.

Recommendations provided in this document are based primarily on
published data. Because randomized trials are unavailable in many facets
of coronary artery disease (CAD) treatment, observational studies and,
in some areas, expert opinion form the basis for recommendations that
are offered. In each section of the Indications (see Section 9 of the
original guideline document), the relative levels of evidence favoring
the Class I, II, and III indications were noted.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Increased familiarity with new evidence on coronary artery bypass
    graft (CABG) surgery

-   Improved clinical decision making regarding appropriate use of CABG
    surgery

-   Improved short- and long-term patient outcomes and satisfaction

#### POTENTIAL HARMS

**Morbidity Associated With Bypass Surgery**

-   *Neurological Events*

> Neurological abnormalities after coronary artery bypass graft (CABG)
> are a dreaded complication. The reported incidence ranges from 0.4% to
> nearly 80%, depending on how the deficit is defined. Neurological
> derangement after CABG has been attributed to hypoxia, emboli,
> hemorrhage, and metabolic abnormalities. Despite the many advances
> made in cardiac surgery, postoperative stroke remains a problem.
> Postoperative neurological deficits have been divided into 2 types:
> type 1 deficits are those associated with major, focal neurological
> deficits, stupor, and coma; type 2 deficits are characterized by
> deterioration in intellectual function or memory. Please refer to the
> full text of the original guideline document for a complete discussion
> of adverse cerebral outcomes and estimation of individual patient
> risk.

-   *Mediastinitis*

> Deep sternal wound infection has been reported to occur in 1 to 4% of
> patients after CABG and carries a mortality rate of nearly 25%.
> Studies have consistently associated obesity and reoperation with this
> complication, while other risk factors such as use of both internal
> mammary arteries, duration and complexity of operation, and the
> presence of diabetes have been reported inconsistently. Most studies
> examining deep sternal wound infection have been single-center,
> retrospective reviews, and variation in wound surveillance techniques
> and the definition of deep sternal wound infection limit comparisons.
> Please refer to the full text of the original guideline document for a
> complete discussion of post-CABG mediastinitis and estimation of
> individual patient risk.

-   *Renal Dysfunction*

> The first major multicenter study of renal dysfunction after CABG
> surgery was published in 1998. This study of 2,222 patients who
> underwent myocardial revascularization with cardiopulmonary bypass
> defined postoperative renal dysfunction (PRD) as a postoperative serum
> creatinine level of greater than or equal to 2.0 mg/dL or an increase
> in the serum creatinine level of greater than or equal to 0.7 mg/dL
> from preoperative to maximum postoperative values. PRD occurred in 171
> (7.7%) of the patients studied; 30 of these (18%, or 1.4% of all study
> patients) required dialysis. The mortality rates were 0.9% among
> patients who did not develop PRD, 19% in patients with PRD who did not
> require dialysis, and 63% among those who required dialysis. Several
> preoperative risk factors for PRD were identified, including advanced
> age, a history of moderate to severe congestive heart failure (CHF),
> prior CABG, type 1 diabetes mellitus, and preexisting renal disease
> (preoperative creatinine levels greater than 1.4 mg/dL). The risk of
> PRD in patients less than 70 years of age nearly tripled with 1
> preoperative risk factor and increased further with 2 risk factors. A
> detailed analysis of the impact of these preoperative risk factors for
> PRD for 3 age groups is presented in Table 4 of the full text of the
> original guideline document. These findings allow identification of
> high-risk patients for PRD and a general estimation of the risk for
> PRD for an individual patient. The reported risk for patients with
> moderate renal dysfunction is consistent with previous reports from
> smaller, single-center studies.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines attempt to define practices that meet the needs of most
patients in most circumstances. The ultimate judgment regarding care of
a particular patient must be made by the healthcare provider and patient
in light of all the circumstances presented by that patient.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The context within which coronary surgery is performed will ultimately
influence the outcome experienced by patients. Because of the highly
technical nature of the procedure and the narrow clinical margin of the
patient population, strategies to ensure consistent care have evolved.
These strategies include establishing specialized cardiac surgical
centers, forming multidisciplinary clinical teams within hospitals, and
creating and implementing clinical pathways, care maps, algorithms, and
protocols.

Appropriately implemented clinical guidelines have been shown to improve
the processes of clinical care in 90% of cases and show measurable
improvement of outcome in 20% of cases. Successful application of
clinical guidelines require they be accompanied by unambiguous statement
of purpose, that clinicians for whom they are intended have some role in
their creation or implementation, and that forcing functions, such as
clinical pathways, algorithms, or protocols, be tied to the guidelines.

Whereas clinical practice guidelines describe an ideal treatment
strategy for a particular disease process, clinical pathways (a.k.a.
critical pathways, care maps) represent the optimal sequence of timing
of interventions for a particular diagnosis or procedure. Well-designed
clinical pathways ensure care is delivered as prescribed by a practice
guideline while optimizing resource utilization, minimizing chance of
error, and allowing for the reinvention of these standards within the
context of local culture. They are typically created for patient
populations that are large in number, relatively homogeneous in
appearance, and consume large amounts of resources and have thus been
found ideal for the coronary artery bypass graft (CABG) population.

#### IMPLEMENTATION TOOLS

Foreign Language Translations\
Patient Resources\
Personal Digital Assistant (PDA) Downloads\
Pocket Guide/Reference Cards\
Tool Kits

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart
JC, Herrmann HC, Hillis LD, Hutter AM Jr, Lytle BW, Marlow RA, Nugent
WC, Orszulak TA. ACC/AHA 2004 guideline update for coronary artery
bypass graft surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines.
Bethesda (MD): American College of Cardiology; 2004. 99 p. \[795
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 Oct (revised 2004)

#### GUIDELINE DEVELOPER(S)

American College of Cardiology Foundation - Medical Specialty Society\
American Heart Association - Professional Association

#### SOURCE(S) OF FUNDING

The American College of Cardiology Foundation (ACCF) and the American
Heart Association (AHA). No outside funding accepted.

#### GUIDELINE COMMITTEE

American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee to Update the 1999 Guidelines for
Coronary Artery Bypass Graft Surgery)

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

The Committee consists of acknowledged experts in cardiac surgery,
interventional cardiology, general cardiology, internal medicine, and
family practice. The Committee included representatives from the
American Academy of Family Physicians (AAFP) and the American College of
Physicians (ACP), as well as the Society for Thoracic Surgery (STS).
Both academic and private practice sectors were represented.

*Writing Committee Members*: Kim A. Eagle, MD, FACC, FAHA (Co-chair);
Robert A. Guyton, MD, FACC, FAHA (Co-chair); Ravin Davidoff, MB, BCh,
FACC, FAHA; Fred H. Edwards, MD, FACC, FAHA; Gordon A. Ewy, MD, FACC,
FAHA; Timothy J. Gardner, MD, FACC, FAHA; James C. Hart, MD, FACC;
Howard C. Herrmann, MD, FACC, FAHA; L. David Hillis, MD, FACC; Adolph M.
Hutter, Jr., MD, MACC, FAHA; Bruce Whitney Lytle, MD, FACC; Robert A.
Marlow, MD, MA, FAAFP; William C. Nugent, MD; Thomas A. Orszulak, MD,
FACC

*Task Force Members*: Elliott M. Antman, MD, FACC, FAHA (Chair); Sidney
C. Smith, Jr., MD, FACC, FAHA (Vice Chair); Joseph S. Alpert, MD, FACC,
FAHA\*; Jeffrey L. Anderson, MD, FACC, FAHA; David P. Faxon, MD, FACC,
FAHA; Valentin Fuster, MD, PhD FACC, FAHA; Raymond J. Gibbons, MD, FACC,
FAHA\*#; Gabriel Gregoratos, MD, FACC, FAHA\*; Jonathan L. Halperin, MD,
FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; Sharon Ann Hunt, MD,
FACC, FAHA; Alice K. Jacobs, MD, FACC, FAHA; Joseph P. Ornato, MD, FACC,
FAHA

\*Former Task Force Member

#Immediate Past Chair

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The American College of Cardiology/American Heart Association (ACC/AHA)
Task Force on Practice Guidelines makes every effort to avoid any actual
or potential conflicts of interest that might arise as a result of an
outside relationship or personal interest of a member of the writing
panel. Specifically, all members of the writing panel are asked to
provide disclosure statements of all such relationships that might be
perceived as real or potential conflicts of interest. These statements
are reviewed by the parent task force, reported orally to all members of
the writing panel at the first meeting, and updated yearly and as
changes occur.

The relationships with industry information for the writing committee
members is posted on the ACC ([www.acc.org](http://www.acc.org/)) and
AHA ([www.americanheart.org](http://www.americanheart.org/)) Web sites
with the full-length version of the update (see Appendix 1 below), along
with the names and relationships with industry of the peer reviewers
(see Appendix 2 below).

Appendix 1: ACC/AHA Committee to Update the 1999 Guidelines for Coronary
Artery Bypass Graft Surgery -- Relationships with Industry

  --------------------------------------------------------------------------------
  **Committee   **Research       **Speakers/ Bureau **Stock       **Consultant**
  Member Name** Grant**          /Honoraria**       Ownership**   
  ------------- ---------------- ------------------ ------------- ----------------
  Dr. Kim A.    Sanofiaventis\   None               None          National
  Eagle         Pfizer\                                           Institutes of
                Blue Cross/Blue                                   Health\
                Shield                                            Sanofiaventis

  Dr. Robert A. Medtronic, Inc\  None               None          Medtronic, Inc.
  Guyton        Quest Medical,                                    
                Inc.\                                             
                Chase Medical,                                    
                Inc.                                              

  Dr. Ravin     None             None               None          None
  Davidoff                                                        

  Dr. Fred H.   None             None               None          None
  Edwards                                                         

  Dr. Gordon A. None             Pfizer\            None          None
  Ewy                            Merck\                           
                                 GlaxoSmithKline\                 
                                 Wyeth                            

  Dr. Timothy   None             None               None          None
  J. Gardner                                                      

  Dr. James C.  Medtronic, Inc.\ Medtronic, Inc.\   None          Medtronic, Inc.\
  Hart          CardioVations    Novare                           St. Jude
                                                                  Medical\
                                                                  CardioVations

  Dr. Howard C. Johnson &        Johnson & Johnson\ Johnson &     Johnson &
  Herrmann      Johnson\         Pfizer             Johnson       Johnson\
                Boston                                            Boston
                Scientific\                                       Scientific\
                Pfizer\                                           Merck
                Merck\                                            
                Millennium                                        

  Dr. L. David  None             None               None          None
  Hillis                                                          

  Dr. Adolph M. None             None               None          None
  Hutter                                                          

  Dr. Bruce     None             None               None          None
  Whitney Lytle                                                   

  Dr. Robert A. None             None               None          None
  Marlow                                                          

  Dr. William   None             None               None          None
  C. Nugent                                                       

  Dr. Thomas A. None             None               None          None
  Orszulak                                                        
  --------------------------------------------------------------------------------

**Note**: This table represents the relationships of committee members
with industry that were disclosed at the initial writing committee
meeting in March 2002 and updated in conjunction with all meetings and
conference calls of the writing committee. It does not necessarily
reflect relationships with industry at the time of publication.

Appendix 2: External Peer Reviewers for the ACC/AHA 2004 Guideline
Update for Coronary Artery Bypass Graft Surgery\*

  ------------------------------------------------------------------------
  **Reviewer     **Reviewer Category and    **Relationships with
  Name\*\***     Affiliation**              Industry**
  -------------- -------------------------- ------------------------------
  Dr. Robert H.  Official Reviewer - ACC    None
  Jones          (Board of Trustees)        

  Dr. Edward H.  Official Reviewer - ACC    None
  Williams       (Board of Governors)       

  Dr. Loren F.   Official Reviewer -        None
  Hiratzka       ACC/AHA Task Force on      
                 Practice Guidelines        

  Dr. Irving L.  Official Reviewer - AHA    None
  Kron                                      

  Dr. Irvin B.   Official Reviewer - AHA    None
  Krukenkamp                                

  Dr. E. Magnus  Official Reviewer - AHA    Stock Holder: Medtronic
  Ohman                                     Research Grants: Berlex,
                                            Millennium, BMS,
                                            Sanofi-Synthelabo, Merck

  Dr. John F.    Organizational Reviewer -  None
  Butterworth    Society of Cardiovascular  
                 Anesthesiologists          

  Dr. Harry J.   Organizational Reviewer -  None
  D\'Agostino,   Society of Thoracic        
  Jr.            Surgeons                   

  Dr. Constance  Organizational Reviewer -  None
  K. Haan        Society of Thoracic        
                 Surgeons                   

  Dr. Elliott M. Content Reviewer - ACC/AHA Research Grants: Bristol-Myers
  Antman         Task Force on Practice     Squibb, Sanofi-Synthelabo,
                 Guidelines                 Millennium, Merck, Eli Lilly
  ------------------------------------------------------------------------

**Note**: This table represents the relationships of peer reviewers with
industry that were disclosed at the time of peer review of this
guideline. It does not necessarily reflect relationships with industry
at the time of publication.

\*Participation in the peer review process doest not imply endorsement
of the document.\
\*\*Names are listed in alphabetical order within each category of
review.

#### ENDORSER(S)

American Association of Thoracic Surgery - Medical Specialty Society\
Society of Thoracic Surgeons - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of
Cardiology, American Heart Association, Eagle KA, Guyton RA, Davidoff R,
Ewy GA, Fonger J, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O\'Connor
GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert
JS, Eagle KA, Garson A Jr, Gregoratos G, Russell RO, Smith SC Jr.
ACC/AHA Guidelines for coronary artery bypass graft surgery. J Am Coll
Cardiol 1999 Oct;34(4):1262-347.

This document will be reviewed one year after the date of publication
and yearly thereafter by the Task Force to determine whether a revision
is needed. The guidelines will be considered current, unless the Task
Force publishes revisions or a withdrawal.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Cardiology (ACC) Web
site](http://www.acc.org/qualityandscience/clinical/guidelines/cabg/index.pdf).

Print copies: Available from ACC, Resource Center, 9111 Old Georgetown
Rd, Bethesda, MD 20814-1699; (800) 253-4636 (US only). Also available
from the American Heart Association (AHA), Public Information, 7272
Greenville Ave, Dallas TX 75231-4596; Reprint No. 71-0281.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Eagle KA, Guyton RA, et al. 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).

> Electronic copies: Available in Portable Document Format (PDF) format
> from the [American College of Cardiology (ACC) Web
> site](http://www.acc.org/qualityandscience/clinical/guidelines/cabg/summary.pdf).

-   ACC/AHA pocket guideline. Coronary artery bypass graft surgery.
    Dallas (TX): American College of Cardiology/American Heart
    Association. 2005 Mar. 58 p.

> Electronic copies: Available in Portable Document Format (PDF) format
> from the [ACC Web
> site](http://www.acc.org/qualityandscience/clinical/guidelines/cabg/index_pkt.pdf).
> A [Palm
> Download](http://www.acc.org/qualityandscience/clinical/palm_download.htm)
> is also available.

Print copies: Available from ACC, Resource Center, 9111 Old Georgetown
Rd, Bethesda, MD 20814-1699; (800) 253-4636 (US only). Also available
from the American Heart Association (AHA), Public Information, 7272
Greenville Ave, Dallas TX 75231-4596; Reprint No. 71-0281.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on December 29, 1999. The information
was verified by the guideline developer on April 17, 2000. This summary
was updated by ECRI on October 13, 2004. The updated information was
verified by the guideline developer on November 3, 2005. This summary
was updated by ECRI on March 6, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Coumadin (warfarin sodium). This
summary was updated by ECRI Institute on September 7, 2007 following the
revised U.S. Food and Drug Administration (FDA) advisory on Coumadin
(warfarin). This summary was updated by ECRI Institute on November 6,
2007, following the U.S. Food and Drug Administration advisory on
Antidepressant drugs.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions as follows:

Copyright to the original guideline is owned by the American College of
Cardiology Foundation (ACCF) and the American Heart Association, Inc.
(AHA). NGC users are free to download a single copy for personal use.
Reproduction without permission of the ACC/AHA guidelines is prohibited.
Permissions requests should be directed to
<copyright_permissions@acc.org>.

### DISCLAIMER

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Date Modified: 11/3/2008