Association of prior coronary artery bypass graft surgery with quality of care of patients with non-ST-segment elevation myocardial infarction: a report from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines

Outcomes of management strategies in patients with prior coronary artery bypass grafting presenting with an acute coronary syndrome

BACKGROUND

Patients with prior coronary artery bypass grafting (CABG) presenting with an acute coronary syndrome (ACS) have poor outcomes and the optimal treatment strategy for this population is unknown.

METHODS

Using linked administrative databases, we examined patients with an ACS between 2008 and 2019, identifying patients with prior CABG. Patients were categorized by ACS presentation type and treatment strategy. Our primary outcome was the composite of death and recurrent myocardial infarction at one year.

RESULTS

Of 54,641 patients who presented with an ACS, 1670 (3.1%) had a history of prior CABG. Of those, 11.0% presented with an ST-elevation myocardial infarction (STEMI) of which, 15.3% were treated medically, 31.1% underwent angiography but were treated medically, 22.4% with fibrinolytic therapy and 31.1% with primary PCI. The primary outcome rate was the highest (36.8%) in patients who did not undergo angiography and was similar in the primary PCI (20.8%) and fibrinolytic group (21.9%). In patients presenting with a non-ST elevation acute coronary syndrome (NSTE-ACS) (89.0%), 33.2% were treated medically, 38.5% underwent angiography but were treated medically and 28.2% were treated with PCI. Compared to those who underwent PCI, patients treated conservatively demonstrated a higher risk of the composite outcome (14.8% vs 27.3%; adjusted hazard ratio 1.70, 95% confidence interval 1.22-2.37).

CONCLUSIONS

Patients with prior CABG presenting with an ACS are often treated conservatively without PCI, which is associated with a higher risk of adverse events.

Acute Coronary Syndromes Among Patients with Prior Coronary Artery Bypass Surgery

PURPOSE OF REVIEW

Acute coronary syndromes (ACS) often occur in individuals with prior coronary artery bypass graft surgery (CABG). Our goal was to describe the prevalence, clinical characteristics, prognosis, and treatment strategies in this group of patients.

RECENT FINDINGS

Studies demonstrate that both acute and long-term major adverse cardiovascular outcomes are increased in patients with ACS and prior CABG compared to those without CABG. Much of this risk is attributed to the greater comorbid conditions present in patients with prior CABG. Data regarding optimal management of ACS in patients with prior CABG are limited, but most observational studies favor an early invasive approach for treatment. Native vessel percutaneous coronary intervention (PCI), if feasible, is generally preferred to bypass graft PCI. Patients with ACS and prior CABG represent a high-risk group of individuals, and implementing optimal preventive and treatment strategies are critically important to reduce the risk.

Clinical Characteristics, Management Strategies, and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction Patients With and Without Prior Coronary Artery Bypass Grafting

Background

There are limited data on the management strategies, temporal trends and clinical outcomes of patients who present with non–ST‐segment–elevation myocardial infarction and have a prior history of CABG.

Methods and Results

We identified 287 658 patients with non–ST‐segment–elevation myocardial infarction between 2010 and 2017 in the United Kingdom Myocardial Infarction National Audit Project database. Clinical and outcome data were analyzed by dividing into 2 groups by prior history of coronary artery bypass grafting (CABG): group 1, no prior CABG (n=262 362); and group 2, prior CABG (n=25 296). Patients in group 2 were older, had higher GRACE (Global Registry of Acute Coronary Events) risk scores and burden of comorbid illnesses. More patients underwent coronary angiography (69% versus 63%) and revascularization (53% versus 40%) in group 1 compared with group 2. Adjusted odds of receiving inpatient coronary angiogram (odds ratio [OR], 0.91; 95% CI, 0.88–0.95; P<0.001) and revascularization (OR, 0.73; 95% CI, 0.70–0.76; P<0.001) were lower in group 2 compared with group 1. Following multivariable logistic regression analyses, the OR of in‐hospital major adverse cardiovascular events (composite of inpatient death and reinfarction; OR, 0.97; 95% CI, 0.90–1.04; P=0.44), all‐cause mortality (OR, 0.96; 95% CI, 0.88–1.04; P=0.31), reinfarction (OR, 1.02; 95% CI, 0.89–1.17; P=0.78), and major bleeding (OR, 1.01; 95% CI, 0.90–1.11; P=0.98) were similar across groups. Lower adjusted risk of inpatient mortality (OR, 0.67; 95% CI, 0.46–0.98; P=0.04) but similar risk of bleeding (OR,1.07; CI, 0.79–1.44; P=0.68) and reinfarction (OR, 1.13; 95% CI, 0.81–1.57; P=0.47) were observed in group 2 patients who underwent percutaneous coronary intervention compared with those managed medically.

Conclusions

In this national cohort, patients with non–ST‐segment–elevation myocardial infarction with prior CABG had a higher risk profile, but similar risk‐adjusted in‐hospital adverse outcomes compared with patients without prior CABG. Patients with prior CABG who received percutaneous coronary intervention had lower in‐hospital mortality compared with those who received medical management.

Clinical Characteristics, Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting

OBJECTIVE

To investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI).

PATIENTS AND METHODS

We undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004-September 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]).

RESULTS

Patients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P=.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P=.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P=.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P<.001), all-cause mortality (OR, 0.45; 95% CI, 0.38 to 0.53; P<.001), and acute ischemic stroke (OR, 0.71; 95% CI, 0.59 to 0.86; P<.001) were observed in group 2 patients who underwent PCI compared with those managed medically without any increased risk of major bleeding (OR, 1.08; 95% CI, 0.94 to 1.23; P=.26).

CONCLUSIONS

In this national cohort, MI patients with prior-CABG had a higher risk profile, but similar in-hospital adverse outcomes compared with CABG-naive patients. Prior-CABG patients who received PCI had better in-hospital clinical outcomes compared to those who received medical management.

Characteristics and Outcome of Patients ≥75 Years of Age With Prior Coronary Artery Bypass Grafting Admitted for an Acute Coronary Syndrome

The prognostic role of previous coronary artery bypass (CABG) in elderly patients admitted to hospital for an acute coronary syndrome (ACS) is unclear. Therefore, the aim of this study was to compare the prognosis of patients aged ≥75 years admitted for an ACS with or without previous history of CABG. The primary outcome of the study was a composite of overall mortality, recurrent nonfatal myocardial infarction, nonfatal stroke, and rehospitalization for heart failure at 1-year follow-up. We included 2,253 ACS patients, aged 81 (78 to 85) years enrolled in 3 multicenter studies (the Italian Elderly ACS study, the LADIES ACS study, and the Elderly ACS 2 randomised trial) - 178 (7.9%) with previous CABG, 2,075 (92.1%) without. Patients with previous CABG had a higher burden of cardiovascular risk factors, lower ejection fraction, and higher creatinine values on admission. However, both at univariate analysis and after adjustment for the most relevant covariates (sex, age, previous myocardial infarction, type of ACS, left ventricular ejection fraction, and serum creatinine on admission), previous CABG did not show any statistically significant association with 1-year outcome (adjusted hazard ratio 0.85; 95% confidence interval 0.61 to 1.19; p = 0.353). In conclusion, our study suggests that elderly ACS patients with previous CABG have worse basal clinical characteristics. Nevertheless, in a broad cohort of patients mostly treated with percutaneous coronary intervention during the index event, previous CABG did not confer independent additional risk of major adverse cardiovascular events at 1-year follow-up.

Impact of previous coronary artery bypass grafting in patients presenting with an acute coronary syndrome: Current trends and clinical implications

BACKGROUND

Among patients presenting with an acute coronary syndrome, those with previous coronary artery bypass grafting are a particular subset.

AIMS

The purpose of this study was to investigate the prognostic impact of previous coronary artery bypass grafting in acute coronary syndrome patients and to identify the current trends in their clinical management.

METHODS

We performed a cohort analysis of patients prospectively enrolled in the Portuguese Registry of acute coronary syndrome between 2010-2019 with known previous coronary artery bypass grafting status. The co-primary endpoints were in-hospital and one-year mortality.

RESULTS

A total of 19,334 (962 coronary artery bypass grafting and 18,372 non-coronary artery bypass grafting) and 9402 (479 coronary artery bypass grafting and 8923 non-coronary artery bypass grafting) patients were included in the analyses of in-hospital and mid-term outcomes, respectively. Coronary artery bypass grafting patients were older and had a higher incidence of comorbidities. They were less likely to undergo invasive angiography (74.9 vs 84.6%, p<0.001), but were equally likely to receive dual antiplatelet therapy (91.0 vs 90.8%, p=0.823). In-hospital mortality was similar between groups (3.6 vs 3.4%, p=0.722). Unadjusted one-year mortality was higher in the coronary artery bypass grafting group (hazard ratio 1.48, 95% confidence interval 1.09-2.01, p=0.012), but similar in both groups after propensity-matching and multivariate analysis (hazard ratio 0.63, 95% confidence interval 0.37-1.09, p=0.098).

CONCLUSIONS

Among patients with acute coronary syndrome, a previous history of coronary artery bypass grafting was associated with a high burden of comorbidities and a high-risk profile but was not an independent predictor of adverse events. Treatment decisions should be made on a case-by-case basis, and should not be based on previous coronary artery bypass grafting status alone.

Outcomes Following Percutaneous Coronary Intervention in Non-ST-Segment-Elevation Myocardial Infarction Patients With Coronary Artery Bypass Grafts

Background There are limited data on outcomes of patients with previous coronary artery bypass graft (CABG) presenting with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI). We compare clinical characteristics and outcomes in non-ST-segment-elevation myocardial infarction patients undergoing PCI with or without prior CABG surgery in a national cohort. Methods and Results We identified 205 039 patients with non-ST-segment-elevation myocardial infarction who underwent PCI between 2007 and 2014 in the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 3 groups: group 1, PCI in native coronary arteries and no prior CABG (n=186 670); group 2, PCI in native arteries with prior CABG (n=8825); group 3, PCI in grafts (n=9544). Patients in group 2 and 3 were older and had more comorbidities and higher mortality at 30 days (group 2, 2.6% and group 3, 1.9%) and 1 year (group 2, 8.29% and group 3, 7.08%) as compared with group 1 (1.7% and 4.87%). After multivariable analysis, no significant difference in outcomes was observed in 30-days mortality (odds ratio; group 2=0.87 [CI, 0.69-1.80; P=0.20], group 3=0.91 [CI, 0.71-1.17; P=0.46]), in-hospital major adverse cardiovascular event (odds ratio: group 2=1.08 [CI, 0.88-1.34; P=0.45], group 3=0.97 [CI=0.77-1.23; P=0.82]), and in-hospital stroke (odds ratio: group 2=1.37 [CI, 0.71-2.69; P=0.35], group 3=1.13 [CI, 0.55-2.34; P=0.73]; group 1=reference). Conclusions Patients with prior CABG are presenting with non-ST-segment-elevation myocardial infarction and treated with PCI had more comorbid illnesses, but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality and major adverse cardiovascular event.

Invasive Versus Medical Management in Patients With Prior Coronary Artery Bypass Surgery With a Non-ST Segment Elevation Acute Coronary Syndrome

Supplemental Digital Content is available in the text.

The benefits of routine invasive management in patients with prior coronary artery bypass grafts presenting with non-ST elevation acute coronary syndromes are uncertain because these patients were excluded from pivotal trials.

Sex-Specific Outcomes After Transcatheter Aortic Valve Replacement: A Review of the Literature

Transcatheter aortic valve replacement (TAVR) is a safe and effective therapy for aortic valve replacement in patients ineligible for or at high risk for surgery. However, outcomes after TAVR based on an individual's sex remain to be fully elucidated. We searched PUBMED and EMBASE using the keywords: "transcatheter aortic valve replacement," "transcatheter aortic valve implantation," "sex differences," "gender," "sex characteristics" and collected information on baseline features, procedural characteristics, and postprocedural outcomes in women. Inclusion/exclusion resulted in 23 publications. Women had less preexisting comorbidities than men. Most studies reported better survival in women (range of hazard ratio [95% CI] = 0.27 [0.09-0.84] to 0.91 [0.75-1.10]). At 30 days, women also had more vascular complications (6-20% vs 2-14%) and higher bleeding rates (10-44% vs 8-25%). Stroke rates were similar at 30 days (women, 1-7%; men, 1-5%). This literature review showed better survival in women than men after TAVR. However, women had more vascular complications and bleeding; stroke rates were similar. These findings may partly be explained by fewer baseline comorbidities in women. These results should be interpreted with caution as most measures only include unadjusted percentages.

Outcomes Following Primary Percutaneous Coronary Intervention in Patients With Previous Coronary Artery Bypass Surgery

BACKGROUND

There are limited data on outcomes of patients with previous coronary artery bypass grafting (CABG) presenting with ST-segment-elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PPCI). We report outcomes in patients with STEMI undergoing PPCI with or without previous CABG surgery in a large real-world, all-comer population.

METHODS AND RESULTS

Clinical, demographic, procedural, and outcomes data were collected for all patients undergoing PPCI in England and Wales from January 2007 to December 2012. All-cause mortality at 30 days and 1 year were evaluated in the whole and a propensity-matched cohort. Of 79 295 patients with STEMI studied, 2658 (3.4%) patients had prior CABG, of whom 44% (n=1168) underwent PPCI to native vessels and 56% (n=1490) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. Patients with prior CABG (with primary PCI to native artery or graft) had higher mortality at 30 days (6.2% with PPCI to native artery, 6.1% with PPCI to bypass graft) than patients with no prior CABG (4.5%; P<0.001). However, after risk factor adjustments, there was no significant difference in outcomes. There were also no significant differences in 30-day mortality, in-hospital major adverse cardiovascular events, in-hospital stroke, and in-hospital bleeding in the propensity-matched population.

CONCLUSIONS

A prior history of CABG in patients presenting with STEMI and undergoing PPCI does not independently confer additional risk of mortality, although it is a marker of other high-risk features.

Non-invasive versus invasive management in patients with prior coronary artery bypass surgery with a non-ST segment elevation acute coronary syndrome: study design of the pilot randomised controlled trial and registry (CABG-ACS)

Introduction

There is an evidence gap about how to best treat patients with prior coronary artery bypass grafts (CABGs) presenting with non-ST segment elevation acute coronary syndromes (NSTE-ACS) because historically, these patients were excluded from pivotal randomised trials. We aim to undertake a pilot trial of routine non-invasive management versus routine invasive management in patients with NSTE-ACS with prior CABG and optimal medical therapy during routine clinical care. Our trial is a proof-of-concept study for feasibility, safety, potential efficacy and health economic modelling. We hypothesise that a routine invasive approach in patients with NSTE-ACS with prior CABG is not superior to a non-invasive approach with optimal medical therapy.

Methods and analysis

60 patients will be enrolled in a randomised clinical trial in 4 hospitals. A screening log will be prospectively completed. Patients not randomised due to lack of eligibility criteria and/or patient or physician preference and who give consent will be included in a registry. We will gather information about screening, enrolment, eligibility, randomisation, patient characteristics and adverse events (including post-discharge). The primary efficacy outcome is the composite of all-cause mortality, rehospitalisation for refractory ischaemia/angina, myocardial infarction and hospitalisation for heart failure. The primary safety outcome is the composite of bleeding, stroke, procedure-related myocardial infarction and worsening renal function. Health status will be assessed using EuroQol 5 Dimensions (EQ-5D) assessed at baseline and 6 monthly intervals, for at least 18 months.

Trial registration number

NCT01895751 (ClinicalTrials.gov).

Prognosis following acute coronary syndromes according to prior coronary artery bypass grafting: Meta-analysis

PURPOSE

Conduct a meta-analysis to study the prognostic influence of a previous coronary artery bypass grafting (CABG) in patients admitted for an acute coronary syndrome (ACS).

METHODS

A systematic review of the literature was performed using electronic reference databases through January 2013 (MEDLINE, Cochrane Library, Web of Knowledge, Google Scholar and references cited in other studies). Studies in which ACS outcomes with a previous history of CABG were compared with ACS outcomes with no history of previous CABG were considered for inclusion. The main endpoints of interest were mortality and non-fatal acute myocardial infarction. Data was aggregated at three follow-up times using random-effects meta-analysis models.

RESULTS

Twenty-four studies were included which provided 387,181 patients for analysis. Previous CABG ACS patients were older, more diabetic and had a more frequent history of a previous myocardial infarction. Pooled in-hospital mortality was higher for the previous CABG ACS patients (OR 1.22 [1.04-1.44], p<0.01, I(2) 88%). The pooled adjusted OR showed no significant differences for the two groups (adjusted OR 1.13 [0.93-1.37], p=0.22, I(2) 92%). Previous CABG ACS patient had a higher pooled 30-day mortality (OR 1.28 [1.05-1.55], p=0.02, I(2) 74%); a higher non-adjusted (OR 1.61 [1.38-1.88], p<0.01, I(2) 70%) and adjusted (adjusted OR 1.37 [1.15-1.65], p<0.01, I(2) 0%) long-term mortality. Both the in-hospital and the long-term re-infarction rates were higher for the previous CABG ACS patients.

CONCLUSIONS

According to our data, ACS patients with previous CABG history had a higher risk for short- and long-term adverse events.

Predictors and outcomes of early coronary angiography in patients with prior coronary artery bypass surgery presenting with non-ST elevation myocardial infarction

Introduction

The best strategy in patients with prior coronary artery bypass graft surgery (CABG) who present with non-ST elevation myocardial infarction (NSTEMI) remains less well defined. We compare the characteristics, therapeutic interventions and outcomes of patients with prior CABG presenting with NSTEMI.

Methods

All patients who presented to our hospital during 2007–2012 with available electronic records were analysed retrospectively. Outcomes were compared between patients who underwent coronary angiography or percutaneous coronary intervention (PCI) versus those who were treated medically.

Results

A total of 117 patients were analysed. Of that, 79 patients were managed medically while 38 underwent early angiography, of which only 11 (9.5%) received PCI. Patients treated medically (did not undergo angiography) were older (74±10 vs70±8; p=0.05). ECG changes were the only independent predictor for early angiography (OR 0.4, 95% CI 0.15 to 0.99; p=0.05) while recurrent chest pain (OR 0.2, 95% CI 0.05 to 0.97; p=0.05) predicted PCI on multivariate analysis. The PCI group had higher Global Registry of Acute Cardiac Events (GRACE) score (176±29 vs 150±31; p=0.01). No significant difference was found in readmission rates, morbidity (unstable angina pectoris, NSTEMI, ST elevation myocardial infarction (STEMI), or combination) or mortality at 12 months between the groups who underwent angiography, PCI, or treated medically on univariate and multivariate analysis.

Conclusions

The opportunity to intervene in prior CABG patients presenting with NSTEMI is often low. Initial medical management may be a reasonable option in carefully selected patients particularly in the absence of ongoing symptoms, ECG changes or very high GRACE scores. Further studies are required to evaluate the safety of non-invasive strategies in managing this population.

Outcomes of patients with prior coronary artery bypass graft who present with acute coronary syndrome

Generally, patients with prior coronary artery bypass graft (CABG) are often under-represented in acute coronary syndrome (ACS) clinical trials. Nevertheless, there is growing global attention concerning their short- and long-term prognosis. Some reports suggest prior CABG as an independent risk factor for increased mortality, while others report an equal or a more favorable prognosis despite their adverse baseline clinical characteristics. The reasons for this 'risk-mortality paradox' need to be further evaluated. More recent reports showed a significant reduction in in-hospital morbidity and mortality over a 20-year period of follow up that may be attributed to the improvement in surgical CABG techniques and increased use of evidence-based therapies over the past two decades. In the current review we discuss the available literature regarding outcomes of prior CABG patients who are presenting with ACS.

Acute coronary syndrome in patients with prior coronary artery bypass surgery: observations from a 20-year registry in a middle-eastern country

Objectives

Clinical characteristics and trends in the outcome of acute coronary syndrome (ACS) in patients with prior coronary artery bypass graft surgery (CABG) are unclear. The aim of this study was to evaluate clinical characteristics, in-hospital treatment, and outcomes in patients presented with ACS with or without a history of prior CABG over 2 decades.

Methods

Data were derived from hospital-based study for collected data from 1991 through 2010 of patients hospitalized with ACS in Doha, Qatar. Data were analyzed according to their history of prior CABG. Baseline clinical characteristics, in-hospital treatment, and outcome were compared.

Results

A total 16,750 consecutive patients with ACS were studied, of which 693 (4.1%) had prior CABG. Patients with prior CABG were older (mean 60.5±11 vs. 53±12 years; P = 0.001), more likely to be females and have more cardiovascular risk factors than the non-CABG group. Prior CABG patients had larger infarct size, were less likely to receive reperfusion therapy, early invasive therapy and more likely to receive evidence-based therapies when compared to non-CABG patients. In-hospital mortality and stroke rates were comparable between the 2 groups. Over 2 decades, there was reduction in the in-hospital mortality rates and stroke rates in both groups (CABG, death; 13.2% to 4%, stroke; 1.9% to 0.0%, non-CABG, death; 10% to 3.2%, stroke 1.0% to 0.1%; all, p = 0.001).

Conclusion

Significant reduction in-hospital morbidity and mortality among ACS patients with prior CABG over a 20-year period.

Does prior coronary artery bypass surgery alter the gender gap in patients presenting with acute coronary syndrome? A 20-year retrospective cohort study

OBJECTIVES

Previous studies demonstrated women presenting with acute coronary syndrome (ACS) have poor outcomes when compared with men 'the gender gap phenomenon'. The impact of prior coronary artery bypass graft (CABG) on women presenting with ACS is unknown. We hypothesised that the gender gap is altered in ACS patients with prior CABG. The aim of this study was to evaluate patients presenting with ACS according to their gender and history of prior CABG.

DESIGN

Retrospective, observational (cohort) study.

SETTING

Data were collected from hospital-based registry of patients hospitalised with ACS in Doha, Qatar, from 1991 through 2010. The data were analysed according to their gender and history of prior CABG.

PARTICIPANTS

A total of 16 750 consecutive patients with ACS were studied. In total, 693 (4.3%) patients had prior CABG; among them 125 (18%) patients were women.

PRIMARY AND SECONDARY OUTCOME MEASURES

Comparisons of clinical characteristics, inhospital treatment, and outcomes, including inhospital mortality and stroke were made.

RESULTS

Women with or without prior CABG were older, less likely to be smokers, but more likely to have diabetes mellitus (DM), hypertension and renal impairment than men (p=0.001). Women were less likely to receive reperfusion and early invasive therapies. When compared with men, women without prior CABG carried higher inhospital mortality (11% vs 4.9%; p=0.001) and stroke rates (0.9% vs 0.3%; p=0.001). Female gender was independent predictor of poor outcome. Among prior CABG patients, despite the fact that women had worse baseline characteristics and were less likely to receive evidence-based therapy, there were no significant differences in mortality or stroke rates between the two groups.

CONCLUSIONS

Consistent with the world literature, women presenting with ACS and without prior CABG had higher death rates compared with men. Patients with prior CABG had comparable death rates regardless of the gender status.