In a field rife with disagreement, STS, AATS, and others say the European guidelines got it right when it comes to CABG.
In a show of solidarity, several organizations representing cardiac surgeons around the world, including those from the US, fully endorsed the 2024 European guidelines for the management of chronic coronary syndromes (CCS).
The endorsement is unique because the Society of Thoracic Surgery (STS) and American Association for Thoracic Surgery (AATS) do not currently support the US guidelines for coronary revascularization, which downgraded CABG surgery for improving survival in select patient groups.
Faisal Bakaeen, MD (Cleveland Clinic, OH), senior author of an editorial endorsing the 2024 European Society of Cardiology (ESC) CCS guidelines, said the surgical groups feel that the ESC recommendations got it right when it comes to surgery's impact.
"Overall, the reason for our satisfaction and endorsement of the [European] guidelines is that we believe the recommendations align with the best possible evidence and that those recommendations would lead to the best results for our patients, including survival," Bakaeen told TCTMD.
In addition to the STS, and AATS, the Latin American Association of Cardiac and Endovascular Surgery (LACES) and the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS) also endorse the European guidelines.
The groups made their views known in an editorial published last week in the Journal of Thoracic and Cardiovascular Surgery.
Disputing ACC/AHA Guidelines
In 2021, the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) published new guidelines for managing patients with STEMI, NSTE ACS, and stable ischemic heart disease. This was followed by another guideline from the ACC/AHA and other groups in 2023 that focused more broadly on managing patients with chronic coronary disease.
While STS and AATS representatives reviewed the revascularization recommendations, neither group endorsed the guidelines. Surgeons were equally critical of the chronic coronary disease guidelines. The major issue with both was that surgery was downgraded from a class I to IIb recommendation as a treatment to improve survival in patients with stable 3-vessel coronary artery disease, preserved left ventricular function, and no left-main coronary artery stenosis.
You want your cardiologist, your surgeon, and everybody who cared for you to be on the same page. Faisal Bakaeen
The ACC/AHA/SCAI writing group downgraded surgery based on data from BARI-2D and ISCHEMIA, noting that the prior class I recommendation for surgery was based on registries, a meta-analysis, and older trials. Surgeons criticized that interpretation, saying the findings from ISCHEMIA -- a study of invasive versus conservative management of chronic coronary disease -- were wrongly extrapolated to compare CABG surgery to optimal medical therapy. They also took issue with the guideline writers focusing on meta-analyses largely comparing PCI versus medical therapy to make assumptions about CABG.
In the ESC chronic coronary disease guidelines, which were developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS), CABG remained a class I recommendation to improve survival and reduce long-term cardiovascular mortality and risk of spontaneous MI for patients with preserved LV function and functionally significant three-vessel CAD. Likewise, in surgically eligible patients with multivessel CAD and LVEF ≤ 35%, CABG surgery was granted a class I recommendation to improve long-term survival over guideline-directed medical therapy alone.
The ESC guidelines also resolved the long-running controversy over the best revascularization option for patients with left-main coronary artery disease, a debate that arose following the EXCEL dustup.
"As cardiologists, we work together in multidisciplinary teams and we very much have mutual respect with our cardiology colleagues," said Bakaeen. "I feel it's really important for us to be on the same page. In the European guidelines, we found an opportunity to do just that."
Bakaeen said the US guidelines decision to downgrade CABG surgery was a mistake, something that has been acknowledged as a "remarkable" demotion by cardiologists, too. In the future, it's critical to have adequate surgical representation as part of the writing committee so that all opinions are heard, he said. In addition, he would like to see decisions made not by simple majority, but rather for guideline committees to develop consensus using other means, such as the Delphi process. External review and public comment periods would also improve guideline development.
"Evidence can be overlooked or maybe misinterpreted inadvertently and you have to have mechanisms to be able to recognize that and correct it," said Bakaeen. "I think we all learned from that experience and it's going to prepare us to work better and more closely with our colleagues on this side of the Atlantic for future recommendations."
He stressed that US cardiac surgeons want to continue collaborate amicably with their nonsurgical colleagues in developing future guidelines, noting that this is what's best for patients. "Put yourself in the shoes of the patients," he said. "You want your cardiologist, your surgeon, and everybody who cared for you to be on the same page."