• Society of Thoracic Surgeons (STS). Gender-specific practice guidelines for coronary artery bypass surgery. Chicago (IL): Society of Thoracic Surgeons (STS); 2004. 20 p. [48 references]

This is the current release of the guideline.

Conditions requiring CABG (coronary artery bypass graft) surgery

Management

Anesthesiology
Cardiology
Thoracic Surgery

Physicians

• To assist physicians and other health care providers in clinical decision-making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions
• To present gender-specific practice guidelines for coronary artery bypass surgery (CABG)

Female patients requiring CABG (coronary artery bypass graft) surgery

1. Use of internal mammary artery in CABG (coronary artery bypass graft surgery)
2. Management of hyperglycemia
3. Management of anemia
4. Off-pump coronary artery bypass graft surgery
5. Management of anesthetic and sedation medications
6. Optimization of thyroxine treatment
7. Preoperative hormone replacement therapy (HRT) (not recommended)

Morbidity and mortality associated with coronary artery bypass surgery (CABG)

Searches of Electronic Databases

Not stated

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Level of Evidence

Level A: Data derived from multiple randomized clinical trials

Level B: Data derived from a single randomized trial or from nonrandomized trials

Level C: Consensus expert opinion

Review

Not stated

Expert Consensus

Not stated

Classification of Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure is useful and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure.

II.a.: Weight of evidence favors usefulness/efficacy
II.b.: Usefulness/efficacy is less well established by evidence

Class III: Conditions for which there is evidence and/or general agreement that the procedure is not useful/effective.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

The levels of evidence (A-C) and classification of recommendations (I-III) are defined at the end of the "Major Recommendations" field.

1. Use of the Internal Mammary Artery
   • Guideline Panel Conclusion: Use of the internal mammary artery is underutilized in women undergoing coronary artery bypass graft (CABG) procedures. The internal mammary artery confers a protective effect that is associated with a significant reduction in CABG mortality as compared to surgical revascularization with venous conduits alone.
   • Ideal Clinical Practice: Whenever it is technically possible, at least one internal mammary artery is used in every coronary artery bypass graft (CABG) procedure to bypass a stenotic coronary artery. Class I, Level B
2. Management of Hyperglycemia
   • Guideline Panel Conclusion: Perioperative blood glucose levels > 150 mg/dl are associated with increased operative morbidity and mortality.
   • Ideal Clinical Practice: Perioperative blood glucose levels are maintained in the range of 100-150 mg/dl. Class I, Level B
3. Management of Anemia
   • Guideline Panel Conclusion: Intraoperative hematocrit levels below 22% are associated with an increased incidence of adverse events.
   • Ideal Clinical Practice: Efforts are made to ensure adequate intraoperative hematocrit levels. Class IIa, Level B
4. Use of Off-Pump CABG (off-pump coronary artery bypass [OPCAB])
   • Guideline Panel Conclusion: There is no evidence to firmly establish the superiority of OPCAB over conventional CABG in the female patient
   • Ideal Clinical Practice: The indications for off-pump coronary artery bypass surgery are the same for women as for men. Class IIa, Level B
5. Adjustment of anesthetic and sedation medications
   • Guideline Panel Conclusion: Failure to account for body size when administering anesthetic and sedative drugs may over-medicate smaller patients.
   • Ideal Clinical Practice: Anesthetic management and sedative utilization during the perioperative period are tailored to body size. Class IIb, Level C
6. Optimization of thyroxine treatment for women with hypothyroidism
   • Guideline Panel Conclusion: Low intraoperative levels of levothyroxine and free thyroxin are associated with a high CABG mortality in hypothyroid women.
   • Ideal Clinical Practice: Hypothyroid women undergoing CABG are maintained in a euthyroid state during surgery. Class IIa, Level C
7. Consideration of preoperative hormone replacement therapy (HRT)
   • Guideline Panel Conclusion: HRT is linked to several complications including serious thromboembolic events. Its use in CABG procedures is of questionable value.
   • Ideal Clinical Practice: Hormone replacement therapy is not used for postmenopausal women undergoing CABG. Class III, Level B

Definitions:

Level of Evidence

Level A: Data derived from multiple randomized clinical trials

Level B: Data derived from a single randomized trial or from nonrandomized trials

Level C: Consensus expert opinion

Classification of Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure is useful and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure.

II.a. Weight of evidence favors usefulness/efficacy
II.b. Usefulness/efficacy is less well established by evidence

Class III: Conditions for which there is evidence and/or general agreement that the procedure is not useful/effective.

None provided

The type of evidence supporting the recommendations is specifically stated for each recommendation (see 'Major Recommendations' field).

Appropriate perioperative management to improve coronary artery bypass graft (CABG) outcomes, particularly in women

Not stated

The use of the internal mammary artery should be avoided when confronted with a soft, friable sternum that predisposes to sternal dehiscence.

These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, these guidelines are subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.

An implementation strategy was not provided.

Getting Better

Effectiveness

• Society of Thoracic Surgeons (STS). Gender-specific practice guidelines for coronary artery bypass surgery. Chicago (IL): Society of Thoracic Surgeons (STS); 2004. 20 p. [48 references]

Not applicable: The guideline was not adapted from another source.

2004

Society of Thoracic Surgeons - Medical Specialty Society

Society of Thoracic Surgeons

Workforce on Evidence-Based Surgery

Not stated

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on March 25, 2005. The information was verified by the guideline developer on April 18, 2005.

© 2004 The Society of Thoracic Surgeons
The Society of Thoracic Surgeons Practice Guidelines may be printed or downloaded for individual and personal use only. Guidelines may not be reproduced in any print or electronic publication or offered for sale or distribution in any format without the express written permission of the Society of thoracic Surgeons.