Surgeons Unite in Backing European Guidelines on Chronic Coronary Syndrome Treatment

In a significant move reflecting unity and professional solidarity, leading cardiac surgeon organizations from around the globe, including representatives from the United States, have openly endorsed the 2024 European Society of Cardiology (ESC) guidelines for managing chronic coronary syndromes (CCS). This endorsement marks a pivotal moment, particularly as prominent groups like the Society of Thoracic Surgery (STS) and the American Association for Thoracic Surgery (AATS) currently stand in disagreement with U.S. guidelines that have controversially downgraded the role of coronary artery bypass grafting (CABG) to improve survival for select patient populations.

Dr. Faisal Bakaeen from Cleveland Clinic, the senior author of an editorial supporting the new ESC guidelines, expressed satisfaction, stating that these recommendations reflect the best available evidence, which ultimately translates into improved outcomes for patients, particularly in terms of survival rates. He noted, “Overall, the reason for our satisfaction and endorsement of the [European] guidelines is that we believe the recommendations align with the best possible evidence and that those recommendations would lead to the best results for our patients, including survival.”

In addition to STS and AATS, the endorsement has garnered support from the Latin American Association of Cardiac and Endovascular Surgery (LACES) and the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), showcasing a global consensus on the efficacy of the European approach to treating chronic coronary conditions. This editorial was published recently in the Journal of Thoracic and Cardiovascular Surgery.

The backdrop to this endorsement involves a heated debate surrounding the American College of Cardiology's (ACC) and American Heart Association's (AHA) guidelines, which were revised in 2021 and further in 2023 to address the complexities of managing various coronary conditions, including stable ischemic heart disease. Many surgical leaders were critical of the decision to downgrade CABG intervention from a class I to a class IIb recommendation, which they argued undervalued its role in improving survival for patients with critical coronary artery disease.

The ACC/AHA’s controversial stance was based on data from studies such as BARI-2D and ISCHEMIA. Critics within the surgical community, however, charged that these findings were misapplied, given that CABG was wrongly compared to optimal medical therapy rather than adequately representing its well-established benefits. Conversely, the ESC guidelines preserved CABG as a class I recommendation for certain patient profiles, including those with multivessel coronary artery disease and preserved left ventricular function, asserting its crucial role in reducing long-term cardiovascular mortality.

These guidelines also seek to address the protracted debate regarding the most effective revascularization strategy for patients with left-main coronary artery disease, a topic that has sparked significant controversy in recent years.

Dr. Bakaeen emphasized the importance of collaborative efforts within multidisciplinary teams of healthcare professionals, asserting that alignment between surgeons and cardiologists is vital for patient care. He criticized the U.S. guidelines’ decision to demote CABG as a mistake, echoing sentiments across the cardiology community that highlighted this shift as a considerable oversight.

Looking ahead, Dr. Bakaeen advocated for more robust surgical representation in the guideline development process, proposing that decision-making should not merely follow a majority vote but rather seek to achieve consensus through deliberative methods, like the Delphi process. He also called for external review and opportunities for public comment as essential steps to enhance the credibility and effectiveness of clinical guidelines.

As these discussions evolve, stakeholders in cardiac care are getting ready to advance the conversation towards a more cohesive approach, ensuring that all perspectives are valued and that patients achieve the optimum care they deserve in this intricate field of medicine.