ACC/AHA GUIDELINES

Recommendations for Early Coronary Angiography in the ST-Segment Elevation or Bundle Branch Block Cohort not Undergoing Primary Percutaneous Transluminal Coronary Angioplasty.

• Class I:
  • None
• Class IIa:
  • Patients with cardiogenic shock or persistent hemodynamic instability.
• Class IIb:
  • Patients with evolving large or anterior infarct treated with thrombolytic agents in whom it is believed that the artery is not patent and adjuvant PTCA is planned.
• Class III:
  • Routine use of angiography and subsequent PTCA within 24 hours of administration of thrombolytic agents.

Recommendations for Emergency or Urgent Coronary Artery Bypass Graft Surgery.

• Class I:
  • Failed angioplasty with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery.
  • Acute MI with persistent or recurrent ischemia refractory to medical therapy in patients with coronary anatomy suitable for surgery who are not candidates for catheter intervention.
  • At the time of surgical repair of postinfarction VSD or mitral valve insufficiency.
• Class IIa:
  • Cardiogenic shock with coronary anatomy suitable for surgery.
• Class IIb:
  • Failed PTCA and small area of myocardium at risk; hemodynamically stable
• Class III:
  • when the expected surgical mortality rate equals or exceeds the mortality rate associated with appropriate medical therapy.

Comment: These recommendations are supplementary to those published in a more complete set of general guidelines and indications for CABG by another ACC/AHA subcommittee and are restricted in general to patients with acute MI and associated complications. The basis for recommending surgery in emergency circumstances is based on the documented benefits of CABG for severe multivessel disease or left main coronary artery stenosis, particularly with reduced LV function, with the realization that risk of emergency CABG is greater than that for elective operation.

ANMCO-SIC CLINICAL GUIDELINES

Surgical revascularization procedures

Surgical revascularization interventions should take place in cases of life-threatening clinical complications (cardiogenic shock, severe mitral valve insufficiency, repair of postinfarction VSD). The use of this surgical intervention in other categories of patients is not at this time recommended because of the limited number of cases studied so far and the limited number of surgical cardiovascular centres in Italy. The resources needed, both in terms of personnel and means, are great and should not be employed in lieu of already proven therapies (type C evidence).