The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

2 CABG should be performed for patients with
unstable angina/NSTEMI who have left main equiva-
lent: signifi cant (greater than or equal to 70%) ste-
nosis of the proximal LAD and proximal left
circumfl ex artery. (Level of Evidence: A)
3 CABG is recommended for unstable angina/
NSTEMI in patients in whom percutaneous revas-
cularization is not optimal or possible, and who
have ongoing ischemia not responsive to maximal
nonsurgical therapy. (Level of Evidence: B)

Class IIa
CABG is probably indicated for patients with
unstable angina/NSTEMI who have proximal LAD
stenosis with 1- or 2-vessel disease. (Level of
Evidence: A)

Class IIb

CABG may be considered in patients with unstable

angina/NSTEMI 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 recom-

mendation becomes Class I.) (Level of Evidence: B)

Timing of surgery is a critical issue is this cate-

gory. In the patient in whom stablilization with

aggressive medical therapy may be achieved, it is

advisable to stabilize and reduce ongoing ischemia

before proceeding to CABG. A small randomized

trial demonstrated that insertion of an IABP 2 hours

or more before CPB can reduce bypass time, intuba-

tion time, and length of stay, as well as improve

Vessel disease

One/two vessels

Three vessels

Left main

Overall

LV function

Normal

Abnormal

Exercise test

Normal

Abnormal

Angina

Class O, I, II

Class III, IV

VA risk score

Low

Moderate

High

Stepwise risk score

Low

Moderate

High

–4 –2 0 2 4 6 8

Extension of survival (mo)

10 12 14 16 18 20

Fig. 7.4 Extension of survival after 10 years of follow-up in various subgroups of patients, from a meta-analysis of seven randomized
studies. LV indicates left ventricular; VA, Veterans Administration. Reprinted with permission from Elsevier Science, Inc. (Yusuf et al. Lancet.
1994;344:563–70).