Recent advances in the management of coronary artery disease: highlights from the literature.
The recent advances in the multidisciplinary management of coronary artery disease (CAD) have been significant. The assessment of patients before percutaneous coronary intervention is likely to change significantly. National compliance with clinical guidelines in the preprocedural assessment of myocardial ischemia should be encouraged. Multislice computed tomographic coronary angiography continues to improve and is already an excellent screening test for CAD. Coronary stenting has an increasing role in multivessel and left main CAD, although further outcome trials are indicated, especially in the elderly. Although off-pump coronary artery bypass graft (CABG) surgery reduces postoperative atrial fibrillation, further major outcome advantages have not been shown in comprehensive meta-analyses when compared with on-pump CABG surgery. Although an intra-aortic balloon pump reduces mortality in high-risk CABG surgery, it may be replaced gradually by the percutaneous left ventricular-assist device, which has shown clinical benefit in this challenging setting. Statin therapy significantly improves clinical outcome after CABG surgery, even when begun postoperatively. There is strong evidence that, unless contraindicated, all CABG patients should receive statin therapy. Clopidogrel therapy just before CABG surgery is still associated with prolonged hospital stay because of significant bleeding complications. This risk will be exacerbated with the advent of the more potent platelet inhibitor, prasugrel. There is a clinical necessity for readily reversible platelet blockade to minimize the bleeding risks in CABG surgery.
Augoustides
John G T
JG
Department of Anesthesia, Cardiothoracic Division, University of Pennsylvania Medical Center, Philadelphia, PA, USA.
Ramakrishna
Harish
H