Coronary artery bypass grafting in acute coronary syndromes: modern indications and approaches

Acute coronary syndromes (ACS) are a leading cause of morbidity and mortality worldwide, with approximately 1.2 million hospitalizations annually in the U.S. This review aims to explore the contemporary evidence regarding revascularization strategies, including percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), in ACS patients. It also addresses the unresolved questions concerning the optimal procedural aspects of surgery and antithrombotic therapy for secondary prevention postsurgery.

Recent studies highlight that while PCI is generally preferred for its timeliness in high-risk non-ST-elevation ACS (NSTE-ACS) patients, CABG offers a benefit in terms of cardiovascular events in those with multivessel disease, particularly in the presence of diabetes and higher coronary disease complexity. For ST-elevation myocardial infarction (STEMI), CABG is less frequently utilized due to the preference for primary PCI, but it remains crucial for patients with complex anatomy or failed PCI. Furthermore, the optimal timing and type of antiplatelet therapy post-CABG remain controversial, with current evidence supporting the use of dual antiplatelet therapy (DAPT) to reduce ischemic events but necessitating careful management to balance bleeding risks.

In patients with ACS, the choice between PCI and CABG depends on the complexity of coronary disease and patient comorbidities. CABG is particularly beneficial for multivessel disease in NSTE-ACS and specific STEMI cases where PCI is not feasible. The management of antiplatelet therapy postsurgery requires a nuanced approach to minimize bleeding risks while preventing thrombotic complications. Further randomized clinical trials are needed to solidify these findings and guide clinical practice.