CHAPTER 44: CORONARY ARTERY BYPASS GRAFTING AND PERCUTANEOUS INTERVENTIONS IN STABLE ISCHEMIC HEART DISEASE

INTRODUCTION

Great advances have been made in the consideration of coronary revascularization for patients with stable ischemic heart disease (SIHD). Perhaps the greatest advance over the past decade has been the establishment of the heart team approach. This is when clinical cardiologists, interventional cardiologists, and cardiovascular surgeons, along with nursing staff, consider together the revascularization options for our patients with SIHD. The heart team approach facilitates better engagement of the patient in the informed consent and decision-making processes.

DEFINITION OF STABLE ISCHEMIC HEART DISEASE

The diagnosis of SIHD is based on symptomatology and primarily obtained through the history of the patient (see Chap. 43). The traditional risk factors for the development of obstructive coronary artery disease (CAD) are ascertained to estimate its likelihood. Stable angina often presents with retrosternal heaviness and aching, which may or may not radiate to the jaw(s) or shoulder(s) and is provoked by exertion or emotional stress and relieved within 5 minutes of rest or nitroglycerine use. Patients with diabetes and other chronic conditions may present with atypical symptoms including the feeling of general malaise after exertion. In combination with the physical examination and 12-lead electrocardiogram (ECG), the important risk markers of hemoglobin A1C, lipid profile, renal and liver function tests, thyroid function tests, and hemoglobin should all be part of the initial evaluation.

ASSESSMENT OF ISCHEMIA ON THE BASIS OF NONINVASIVE TESTING

The identification of ischemic heart disease has largely relied on the documentation of ischemia by noninvasive testing (see Chap. 43). Noninvasive testing largely pertains to patients who are at intermediate risk for establishment of SIHD. Because the workup of noninvasive testing will be the topic of another chapter, it is important to emphasize that noninvasive testing is reserved for men aged over 40 years and women aged over 60 years with a strong history of the presence of angina. With the advancement of noninvasive technology spanning into computed tomography (CT), stress methoxyisobutylisonitrile (MIBI), and echocardiography, the most reliable noninvasive test should be accessible and of high expertise. The choice of noninvasive testing is based on whether or not the ECG is normal or whether or not a left bundle branch block or ventricular paced rhythm is present.

OPTIMAL MEDICAL EXPERTISE

All patients with a history of SIHD should be treated with optimal medical therapy (OMT; see Chap. 43), and it is important to follow evidence-based guidelines for OMT for all patients considered for coronary revascularization.¹ Routinely, patients would receive aspirin daily with or without additional P2Y₁₂ inhibitor antiplatelet therapy depending on the history of ischemic acute coronary syndrome. All patients with SIHD should be on a potent statin therapy and at high doses. All patients should be considered for an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, in particular patients with low ejection fraction, chronic kidney disease, diabetes, or ...