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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e30

CLINICAL STATEMENTS AND GUIDELINES

3.2 Predicting Patient Risk of Death With CABG

Recommendation for Predicting Patient Risk of Death With CABG Referenced studies that support the recommendation are summarized in Online Data Supplements 3.

COR LOE Recommendation

1 B-NR 1.	 In patients who are being considered for CABG, calculation of the STS risk score is recommended to help stratify patient risk.1,2

Synopsis The STS risk score is designed to predict adverse outcomes in patients undergoing CABG, including the risk of death, renal failure, permanent stroke, prolonged ventilation, deep sternal wound infection, reoperation, and prolonged length of stay. The STS risk score is derived from data on patients undergoing CABG in the United States. The STS score is periodically updated to reflect new risk models for CABG, with the most recent update in 2018 based on the Adult Cardiac Surgery Database from 2011–2014.3,4 Similar to the STS score, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, developed in 2011, is designed to predict adverse outcomes in patients undergoing isolated CABG.5

Recommendation-Specific Supporting Text

1.	 The STS risk score has been validated in several studies and demonstrates excellent predictive value for estimating risk of adverse events.2-4 The STS risk score serves as a useful tool when a choice is being made among various treatment strategies because it allows the clinician, the patient, and the patient’s family to have a reasonable estimate of operative risk. The STS risk score performs better than the EuroSCORE II for the patient population with CABG, particularly at higher (>5%) predicted mortality rates.1,2 Commonly used cardiac surgery risk models, such as the STS and EuroSCORE II, are limited in assessing the influence of risk factors, including cirrhosis, frailty, and malnutrition, on outcome. Patients with liver cirrhosis, frailty, and malnutrition have increased risk of perioperative morbidity and mortality after cardiac surgery6-17 and may be assessed by other tools (Table 5).

4 DEFINING LESION SEVERITY

4.1 Angiography to Define Anatomy and

Assess Lesion Severity Coronary angiography remains the default method to define coronary anatomy and characterize the severity of coronary arterial stenoses. A visually estimated diameter stenosis severity of ≥70% for non–left main disease and ≥50% for left main disease has been used to define significant stenosis and to guide revascularization strategy. Although the length of a lesion may contribute to physiological lesion severity (ie, a longer moderate lesion may result in more ischemia than a focal severe lesion), there are no standard cutoffs for lesion length used to classify a

Table 4.  Factors for Consideration by the Heart Team Coronary Anatomy Left main disease Multivessel disease High anatomic complexity (ie, bifurcation disease, high SYNTAX score) Comorbidities Diabetes Systolic dysfunction Coagulopathy Valvular heart disease Frailty Malignant neoplasm End-stage renal disease Chronic obstructive pulmonary disease Immunosuppression Debilitating neurological disorders Liver disease/cirrhosis Prior CVA Calcified/porcelain aorta Aortic aneurysm Procedural Factors Local and regional outcomes Access site for PCI Surgical risk PCI risk Patient Factors Unstable presentation or shock Patient preferences Inability or unwillingness to adhere to DAPT Patient social support Religious beliefs Patient education, knowledge, and understanding CVA indicates cerebrovascular accident; DAPT, dual antiplatelet therapy; PCI, percutaneous coronary intervention; and SYNTAX, Synergy Between PCI With TAXUS and Cardiac Surgery. Table 5.  Assessment of Risk Factors Not Quantified in the STS Score

Risk Factor Assessment Tool Cirrhosis Model for End-Stage Liver Disease (MELD) score1-6 Frailty Gait speed8,10-14,16 Malnutrition Malnutrition Universal Screening Tool (MUST)7,9,15,16 STS indicates Society of Thoracic Surgeons.

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