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Surgeon Perspective on the 2023 Chronic Coronary Disease Guidelines: An Interview with Faisal Bakaeen

Tuesday, August 8, 2023

In response to the release of the updated 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease, authors representing the AATS and STS came together to write a rebuttal explaining their perspective on the controversial guidelines. In an interview with CTSNet Editor in Chief Joel Dunning, revascularization specialist and AATS representative Dr. Faisal Bakaeen elaborates on the surgeons’ perspective.

What follows is video as well as a transcript of their conversation, edited for length and clarity. 

For additional context, see also the recording of a CTSNet webinar that brought together global experts to discuss implications of the 2021 Revascularization Guidelines—the precursor to the 2023 update—on patient care and outcomes around the world.

Joel Dunning: What are some of the highlights of the recommendations in the new guidelines, particularly with regard to revascularization? How did the authors come to make these decisions?
Faisal Bakaeen: Please keep in mind that everything I say today reflects my own personal opinion.

Faisal Bakaeen: With regard to the 2023 Chronic Coronary Disease Patient Management Guidelines, the surgical community was disappointed. The document itself had some really excellent content, virtually everything related to coronary artery disease except the section on revascularization. 

Why do we have a problem with the revascularization section? Well, because it was a replica of the 2021 AHA/ACCA guidelines on revascularization. In it, CABG was downgraded without meaningful evidence, without relevant evidence. What they did was downgrade CABG in patients with normal left ventricle function. And in patients with mild to moderate, it will be dysfunction relative to medical therapy with survival as an endpoint. So CABG remained class I in patients with multivessel disease and CV. But in those with normal function it dropped to class 2B, and in those with mild to moderate disfunction, it dropped to class 2A. There are other issues as well, but it is the downgrade that really was unexpected and unjustified.

They also equated CABG with PCI [percutaneous coronary intervention], and we know those two modalities are totally different. They’re actually complementary rather than competing. We should focus now, perhaps, on the downgrade for survival.

JD: Yes, and maybe say a few words about that evidence. I mean, we’ve got the Syntax trial, we’ve got the ten-year follow-up on Syntax, we’ve got an amazing meta-analysis of several studies showing the superiority of CABG over PCI in these patients. Are you convinced, like I am, that this is Grade I evidence of CABG superiority over PCI?

FB: I’m glad you mentioned that. Relative to PCI, the 2021 guidelines have given the upper hand to CABG in patients with three-vessel disease that is complex, especially with a higher syntax score. So that’s not an issue of controversy. They acknowledged that, and that is consistent in the 2023 recommendations. 

Our argument was, if you are saying that CAG is superior to PCI in survival, regardless of the EF [ejection fraction] in patients with three-vessel disease, how could it be of questionable benefit compared to medical therapy? There is no study that was ever published to confirm that PCI is harmful compared to medical therapy. So with regards to the evidence specifically between CABG and medical therapy, the evidence that we have in randomized patients between medical therapy and CABG is the use of meta-analysis that clearly demonstrates the survival advantage for CABG, regardless of the EF, and the European study, which again demonstrated the same, even in patients with two vessel disease and proximal LAD [left anterior descending artery disease]. But the guidelines committee said, “Oh, these are old studies. Medical therapy got better.”

We agree. That is why we would like all our patients to be on optimal medical therapy. And if you look at CABG, that has improved as well. We bring to their attention that in the use of meta-analysis in the nineties, the thirty-day mortality of CABG was 3 percent. In the study that just got published recently, the thirty-day mortality of CABG was three in a thousand. So CABG mortality decreased by a factor of ten. So did medical therapy improve by a factor of ten? I doubt it.

The ideas of both studies are old, and that the medical therapy is better—they need to actually acknowledge that CABG got better as well, so then when they say they’re going to present you with new evidence, well, that’s where the problem is. 

The new evidence really is not relevant to CABG versus medical therapy. Why? Because in the ischemia study, which is the main study, the cornerstone of the downgrade did not randomize a single patient to CABG or PCI. It was a strategy using a conservative approach where you just treat them medically, or you do a diagnostic cath, and then, based on the diagnostic cath, you could decide if you want to rasterize or not. So not a single patient was randomized to CABG. Secondly, only less than 25 percent of patients had CABG, and three quarters of the interventions were actually PCI.

And finally, how many people do you think had severe proximal LA disease? Very little—36 percent—actually had greater than 50 percent proximal LA disease. I can’t remember the last time that I did a CABG on a patient without a significant proximal LAD lesion.

So clearly neither the ischemia nor meta-analysis studies are based on randomized evidence in which CABG is adequately represented and in which the complexity and the burden of patients are taken into consideration. Because if you look at the STS Database, you find that many more of them are diabetic compared to the ischemia population, and you find that the STS patients are two to four times more likely to have severe vascular disease or heart failure compared to the ischemia patients.

JD: Do you want to say a little bit about why the technical methodology was wrong in the creation of these guidelines?

FB: Yes. We basically explained from the get-go that the 2021 committee did not take those facts into consideration. We also stated that we agree that ischemia is useful, but it was taken beyond the scope for which it was designed. So what the evidence really shows is that it is reasonably safe to treat patients with stable coronary artery disease medically as the first line and to follow up very closely, then offer operative intervention as needed. Those patients need to satisfy the ischemia population criteria in terms of their burden and physiological risk. So maybe we should say that it is class 2A for medical management and three vessel disease with those criteria, but they said no, that’s contradicting the 2021 guidelines.

Marc Ruel and I reasoned again why the evidence just does not match the recommendations. And then we were told, “You can’t relitigate the 2021 guidelines without new evidence.” And then we countered that we are a scientifically independent committee from the 2021 guidelines. Now, I have to make that very clear. That discussion wasn’t between the members of the writing committee; that was between us, the surgeons, and the leadership. So it was the leadership that gave us instructions. Instructions that are counter to what we expected. We expected a robust, scientifically independent writing committee that will make their own judgements, vote without duress, and vote based on what the evidence demonstrates. So that was disappointing. 

Despite us—as we wrote in our rebuttal that was published earlier this week—participating in almost every single call that we could make it to for the writing committee, writing our sections, and reviewing other sections, we reached a point where it came to the vote. And we made it clear that we would not participate in the vote unless our concerns were heard, unless the science is given a fair opportunity to be reviewed and decided upon by this new and very talented committee that I respect completely. But we could never reach that stage, unfortunately. 

And with close discussions between me and Marc, and the AATS and STS, we decided that the best course of action was, unfortunately, to end our participation. It was a sad moment. We put in a lot of hard work, and we had the solution. I’m fairly confident we would have had the momentum to reach good and accurate recommendations and compress recommendations if we were given the opportunity. Because, again, we had an excellent writing committee that I have tremendous respect for. So I don’t blame the writing committee for the final product.

JD: What can the STS and AATS and surgeons around the world do in this situation? We have always found that we are outnumbered [by cardiologists], so what do you think the next step should be for us, as a community of surgeons?

FB: I mean, we love our cardiology colleagues. We got along with the writing committee members just fine, and at our respective hospitals we work really well for the most part, except when it comes to leadership levels and the guidelines. There is a disconnect, and I can’t quite understand why this should exist. If you look back historically, surgeons have worked really well with ACA, and produced excellent guidelines, guidelines that were contradicted with the current ones. So maybe we should have a serious, open, and honest discussion about how we want it to progress in the future. We all want it to work, there is no question about it. 

For start, I think for the procedure-based guidelines we should be like the Europeans. If we’re talking about PCI versus CABG, then you should have fifty-fifty representation between the interventional cardiologists and the surgeons. There is no reason why you wouldn’t. In disease-based guidelines, it gets a little more complex because you need to introduce nonprocedural lists. But that is fine. I think what we have in the STS and AATS, and I think the Europeans do too, is a Delphi process whereby you need 75 percent agreement to pass a recommendation. The current ACA guideline process, as we pointed out in our rebuttal, is only a simple majority. And the surgeons will never achieve that. So if you use a Delphi process and you make it totally open and transparent, and even include dissenting discussions and opinions, allow a period for public comments, and respond to the public comments, I think nearly all our problems will be solved. 

So I think there is still room for us to collaborate. I don’t see a future where the surgeons and the cardiologists wouldn’t work together on guidelines. Right now, I think the surgeons have extended an olive branch. We were critical in our rebuttal, but the last paragraph was, “We look forward to working with the ACA where there is a fair process, a robust process, an unbiased process, and an open process.” Transparency is critical.

JD: Thank you for joining us, Faisal. And thank you again for your amazing leadership.

FB: One last thing that I have to mention: There is some literature about the dangers of postponing CABG when it is indicated. And doing high-risk CABG in patients who are in urgent situations or diminished EF is something that you want to avoid. So we are advocating for our profession, working together with our colleagues, and also protecting our patients. Thank you so much for giving me this opportunity.


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