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Park DY, Singireddy S, Mangalesh S, Fishman E, Ambrosini A, Jamil Y, Vij A, Sikand NV, Ahmad Y, Frampton J, Nanna MG. The association of timing of coronary artery bypass grafting for non-ST-elevation myocardial infarction and clinical outcomes in the contemporary United States. Coron Artery Dis 2024; 35:261-269. [PMID: 38164979 DOI: 10.1097/mca.0000000000001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA. METHODS We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24 h, 24-72 h, 72-120 h, and >120 h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost. RESULTS A total of 147 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120 h and at >120 h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24 h from admission. In addition to these differences, CABG at >120 h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24 h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24 h. CONCLUSION CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | | | - Sridhar Mangalesh
- Department of Medicine, Army College of Medical Sciences, New Delhi, Delhi, India
| | | | | | - Yasser Jamil
- Department of Medicine, Yale-Waterbury Hospital, New Haven, Connecticut
| | - Aviral Vij
- Division of Cardiology, Cook County Health
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Nikhil V Sikand
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Tomura N, Honda S, Takegami M, Nishihira K, Kojima S, Takayama M, Yasuda S. Characteristics and In-Hospital Outcomes of Patients Who Underwent Coronary Artery Bypass Grafting during Hospitalization for ST-Segment Elevation or Non-ST-Segment Elevation Myocardial Infarction. Ann Thorac Cardiovasc Surg 2024; 30:23-00016. [PMID: 37423750 PMCID: PMC10851447 DOI: 10.5761/atcs.oa.23-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/11/2023] [Indexed: 07/11/2023] Open
Abstract
PURPOSE Little is known about the outcomes of patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) who undergo coronary artery bypass grafting (CABG) in the current percutaneous coronary intervention (PCI) era. METHODS We analyzed 25120 acute myocardial infarction (AMI) patients hospitalized between January 2011 and December 2016. In-hospital outcomes were compared between patients who underwent CABG during hospitalization and those who did not undergo CABG in the STEMI group (n = 19428) and NSTEMI group (n = 5692). RESULTS Overall, CABG was performed in 2.3% of patients, while 90.0% of registered patients underwent primary PCI. In both the STEMI and NSTEMI groups, patients who underwent CABG were more likely to have heart failure, cardiogenic shock, diabetes, left main trunk lesion, and multivessel disease than those who did not undergo CABG. In multivariable analysis, CABG was associated with lower all-cause mortality in both the STEMI group (adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] 0.26-0.72) and NSTEMI group (adjusted OR = 0.34, 95% CI 0.14-0.84). CONCLUSION AMI patients undergoing CABG were more likely to have high-risk characteristics than those who did not undergo CABG. However, after adjusting for baseline differences, CABG was associated with lower in-hospital mortality in both the STEMI and NSTEMI groups.
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Affiliation(s)
- Nobunari Tomura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kensaku Nishihira
- Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki, Miyazakai, Japan
| | - Sunao Kojima
- Department of Internal Medicine, Sakurajyuji Yatsushiro Rehabilitation Hospital, Yatsushiro, Kumamoto, Japan
| | - Morimasa Takayama
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Gomes DA, Rocha BM, Ferreira J, Paiva MS, Reis Santos R, Santos MR, Cunha G, DE Araújo Gonçalves P, Fevereiro S, Trabulo M, Aguiar C, Sousa-Uva M, Neves J, Mendes M. Pretreatment with a P2Y12 receptor inhibitor and delay to coronary artery bypass surgery in patients with non-ST segment elevation acute coronary syndrome. Minerva Cardiol Angiol 2023; 71:582-589. [PMID: 36475547 DOI: 10.23736/s2724-5683.22.06199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND 2020 ESC guidelines for non-ST elevation acute coronary syndromes (NSTE-ACS) recommend against the pretreatment with P2Y12 receptor inhibitors (P2Y12i) in patients undergoing early invasive management (<24 h). The rationale is, in part, to prevent bleeding complications and the delay of coronary artery bypass graft surgery (CABG) in patients with suitable coronary anatomy. This study aimed to analyze the theoretical impact of pretreatment with a P2Y12i on delay to CABG surgery in a real-world population with NSTE-ACS. METHODS Single-center retrospective cohort of consecutive patients with NSTE-ACS undergoing invasive evaluation in 2019. Those with previous CABG or nonobstructive coronary disease were excluded. RESULTS The total cohort included 262 patients (mean age 68±12 years, 69% male, 15% with unstable angina and mean GRACE score 134±35). Median time from FMC to angiography was 2 (1-4) days. Overall, 168 (64%) patients underwent percutaneous coronary intervention, 47 (18%) were proposed for CABG and the remainder received conservative management. All patients considered for CABG received pretreatment with P2Y12i (clopidogrel or ticagrelor). The median time from angiography to CABG was 12 (7-15) days. Six patients experienced recurrent angina (13%) and 2 (4%) died before surgery due to refractory ventricular fibrillation. Those who underwent CABG under P2Y12i effect were more likely to receive blood and platelets transfusions (64.7% vs. 28.6%, P=0.017 and 82.4% vs. 21.4%, P<0.001, respectively), although there were no differences regarding major bleeding. CONCLUSIONS Pretreatment with P2Y12i was a potential but not the sole driver of CABG delay in our cohort. Adopting the new recommendations of withholding pretreatment might decrease this delay, but other factors must be considered.
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Affiliation(s)
- Daniel A Gomes
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal -
| | - Bruno M Rocha
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Jorge Ferreira
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Mariana S Paiva
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Rita Reis Santos
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Marina R Santos
- Department of Cardiology, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | - Gonçalo Cunha
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Pedro DE Araújo Gonçalves
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Susana Fevereiro
- Department of Hemotherapy, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Marisa Trabulo
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Carlos Aguiar
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Sousa-Uva
- Department of Cardio-Thoracic Surgery, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - José Neves
- Department of Cardio-Thoracic Surgery, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Mendes
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
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Nabovati E, Farzandipour M, Sadeghi M, Sarrafzadegan N, Noohi F, Sadeqi Jabali M. A Global Overview of Acute Coronary Syndrome Registries: A Systematic Review. Curr Probl Cardiol 2023; 48:101049. [PMID: 34780868 DOI: 10.1016/j.cpcardiol.2021.101049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/05/2021] [Indexed: 12/16/2022]
Abstract
The present study was conducted with the aim of identifying, and summarizing the characteristics of ACS registries at national, multinational and international levels. Literature was searched using keywords in the title and/or abstract without any time limit ending in March, 2021. After excluding duplicates, 2 reviewers independently reviewed the titles and/or abstracts and full text for inclusion. Each reviewer independently extracted the characteristics of the registries from included papers. Finally, the extracted characteristics were confirmed by a second reviewer. Out of the 1309 papers included, 71 ACS registries were identified (including 60 national and 11 multinational and international registries). Most national registries were being used in Europe. Most registries focused on measuring quality. In more than half of the registries, all types of ACS patients were enrolled. The diagnostic and drug classification systems were mentioned in eight and five registries, respectively. The design of 55 registries was hospital-based. The ability of computerized audit checks was made for 34 registries. More than half of the registries had patient consent and had a web-based design. In all the ACS registries, patient characteristics, clinical characteristics and treatment characteristics were recorded and post-discharge follow-up information was recorded in 45 registries. In the current situation and given that a limited number of countries in the world have national ACS registries, reviewing the results of this study and modeling the registries implemented in the leading countries can help countries without a registry to design it.
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Affiliation(s)
- Ehsan Nabovati
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Mehrdad Farzandipour
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran.
| | - Masoumeh Sadeghi
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nizal Sarrafzadegan
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Feridoun Noohi
- Iranian Network of Cardiovascular Research, Iran; Cardiovascular Intervention Research Center, Shaheed Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | - Monireh Sadeqi Jabali
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran.
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Bernard C, Morgant MC, Jazayeri A, Perrin T, Malapert G, Jazayeri S, Bernard A, Bouchot O. Optimal Timing of Coronary Artery Bypass Grafting in Haemodynamically Stable Patients after Myocardial Infarction. Biomedicines 2023; 11:979. [PMID: 36979958 PMCID: PMC10046680 DOI: 10.3390/biomedicines11030979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/21/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
During the acute phase of myocardial infarction, the culprit artery must be revascularized quickly with angioplasty. Surgery then completes the procedure in a second stage. If emergency surgery is performed, the resulting death rate is high; 15-20% of patients are operated on within the first 48 h after the myocardial infarction. The timing of surgical revascularization and the patient's preoperative state influence the mortality rate. We aimed to evaluate the impact of surgery delay on morbimortality. Between 2007 and 2017, a retrospective monocentric study was conducted including 477 haemodynamically stable patients after myocardial infarction who underwent an urgent coronary bypass. Three groups were described, depending on the timing of the surgery: during the first 4 days (Group 1, n = 111, 23%), 5 to 10 days (Group 2, n = 242, 51%) and after 11 days (Group 3, n = 124, 26%). The overall thirty-day mortality was 7.1% (n = 34). The death rate was significantly higher in Group 1 (n = 16; 14% vs. n = 10; 4.0% vs. n = 8; 6%, p < 0.01). The mortality risk factors identified were age (OR: 1.08; CI 95%: 1.04-1.12; p < 0.001), peripheral arteriopathy (OR: 3.31; CI 95%: 1.16-9.43; p = 0.024), preoperative renal failure (OR: 6.39; CI 95%: 2.49-15.6; p < 0.001) and preoperative ischemic recurrence (OR: 3.47; CI 95%: 1.59-7.48; p < 0.01). Ninety-two patients presented with preoperative ischemic recurrence (19%), with no difference between the groups. The optimal timing for the surgical revascularization of MI seems to be after Day 4 in stable patients. However, timing is not the only factor influencing the death rate: the patient's health condition and disease severity must be considered in the individual management strategy.
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Affiliation(s)
- Chloé Bernard
- Department of Cardiac Surgery, Dijon University Hospital, 21000 Dijon, France
| | | | - Aline Jazayeri
- Department of Cardiac Surgery, Dijon University Hospital, 21000 Dijon, France
| | - Thomas Perrin
- Department of Digestive Surgery, Dijon University Hospital, 21000 Dijon, France
| | - Ghislain Malapert
- Department of Cardiac Surgery, Dijon University Hospital, 21000 Dijon, France
| | - Saed Jazayeri
- Department of Cardiac Surgery, Dijon University Hospital, 21000 Dijon, France
| | - Alain Bernard
- Department of Cardiac Surgery, Dijon University Hospital, 21000 Dijon, France
| | - Olivier Bouchot
- Department of Cardiac Surgery, Dijon University Hospital, 21000 Dijon, France
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Krasivskyi I, Djordjevic I, Ivanov B, Eghbalzadeh K, Großmann C, Reichert S, Radwan M, Sandoval Boburg R, Sabashnikov A, Schlensak C, Wahlers T, Rustenbach CJ. Consequences of Obesity on Short-Term Outcomes in Patients Who Underwent Off-Pump Coronary Artery Bypass Grafting Surgery. J Clin Med 2023; 12:jcm12051929. [PMID: 36902716 PMCID: PMC10003424 DOI: 10.3390/jcm12051929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
The correlation between off-pump coronary artery bypass (OPCAB) surgery and obesity-related outcomes is still uncertain. The aim of our study was to analyse the pre-, intra-, and postoperative short-term outcomes between obese and non-obese patients after off-pump bypass surgery. We performed a retrospective analysis from January 2017 until November 2022, including a total of 332 (non-obese (n = 193) and obese (n = 139)) patients who underwent an OPCAB procedure due to coronary artery disease (CAD). The primary outcome was all-cause in-hospital mortality. Our results showed no difference regarding mean age of the study population between both groups. The use of the T-graft technique was significantly higher (p = 0.045) in the non-obese group compared to the obese group. The dialysis rate was significantly lower in non-obese patients (p = 0.019). In contrast, the wound infection rate was significantly higher (p = 0.014) in the non-obese group compared to the obese group. The all-cause in-hospital mortality rate did not differ significantly (p = 0.651) between the two groups. Furthermore, ST-elevation myocardial infarction (STEMI) and reoperation were relevant predictors for in-hospital mortality. Therefore, OPCAB surgery remains a safe procedure even in obese patients.
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Affiliation(s)
- Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
- Correspondence: ; Tel.: +49-176-353-88-719
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Helios Hospital Siegburg, 53721 Siegburg, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Clara Großmann
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Stefan Reichert
- Department of Cardiothoracic Surgery, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Medhat Radwan
- Department of Cardiothoracic Surgery, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Rodrigo Sandoval Boburg
- Department of Cardiothoracic Surgery, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Christian Schlensak
- Department of Cardiothoracic Surgery, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
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Benedetto U, Sinha S, Mulla A, Glampson B, Davies J, Panoulas V, Gautama S, Papadimitriou D, Woods K, Elliott P, Hemingway H, Williams B, Asselbergs FW, Melikian N, Krasopoulos G, Sayeed R, Wendler O, Baig K, Chukwuemeka A, Angelini GD, Sterne JAC, Johnson T, Shah AM, Perera D, Patel RS, Kharbanda R, Channon KM, Mayet J, Kaura A. Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction (NIHR Health Informatics Collaborative: TROP-CABG study). Int J Cardiol 2022; 362:14-19. [PMID: 35487318 DOI: 10.1016/j.ijcard.2022.04.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 11/05/2022]
Abstract
Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction(NIHR Health Informatics Collaborative:TROP-CABG study). Benedetto et al. BACKGROUND: The optimal timing of coronary artery bypass grafting (CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a) the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b) the interaction between troponin and time-to-surgery. METHODS AND RESULTS: Our cohort consisted of 1746 patients (1684 NSTEMI; 62 unstable angina) (mean age 69 ± 11 years,21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early (within 30 days) and late (beyond 30 days) survival. Average interval from peak troponin to surgery was 9 ± 15 days, with 1466 (84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4 ± 2 years (30-day survival 0.97 ± 0.004 and 5-year survival 0.83 ± 0.01). Peak troponin was a strong predictor of early survival (adjusted P = 0.002) with a significant interaction with time-to-surgery (P interaction = 0.007). For peak troponin levels <100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days (adjusted P = 0.64). CONCLUSIONS: Peak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.
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Affiliation(s)
- Umberto Benedetto
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK; University Gabriele D'Annunzio Chieti Pescara, Italy
| | - Shubhra Sinha
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Abdulrahim Mulla
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Benjamin Glampson
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Jim Davies
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vasileios Panoulas
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Sanjay Gautama
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Dimitri Papadimitriou
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Kerrie Woods
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Elliott
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK; Health Data Research UK, London, UK
| | - Harry Hemingway
- Health Data Research UK, London, UK; NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Bryan Williams
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Folkert W Asselbergs
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Narbeh Melikian
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - George Krasopoulos
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rana Sayeed
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Olaf Wendler
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - Kamran Baig
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Andrew Chukwuemeka
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Gianni D Angelini
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
| | - Jonathan A C Sterne
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tom Johnson
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ajay M Shah
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - Divaka Perera
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Riyaz S Patel
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Rajesh Kharbanda
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Keith M Channon
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jamil Mayet
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Amit Kaura
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
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8
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Yan L, Zhou Y, Yu Z, Xuan M, Xu B, Peng F. P2Y12 inhibitor pretreatment in patients with nonST-segment elevation acute coronary syndrome: A meta-analysis. Medicine (Baltimore) 2022; 101:e29824. [PMID: 35801776 PMCID: PMC9259160 DOI: 10.1097/md.0000000000029824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The 2020 European Society of Cardiology guidelines do not recommend pretreatment for nonST-segment elevation myocardial infarction (NSTEMI) patients with unclear coronary anatomy, which is inconsistent with our routine preoperative approach to loading P2Y12 receptor inhibitors (e.g., preoperative loading of 300 mg of clopidogrel). OBJECTIVES The purpose of our study was to compare the safety and effectiveness of P2Y12 inhibitors administered before coronary angiography or at least before percutaneous coronary intervention (PCI) with during or after PCI. METHODS Cochrane, PubMed, and Embase databases were searched. The primary effect endpoint and safety endpoint were any-cause death and major bleeding, respectively. Major adverse cardiovascular events, myocardial infarction and revascularization were also analyzed. RESULTS Our search identified 9 trials. P2Y12 inhibitor pretreatment was associated with lower death from any cause (OR 0.62, 95% CI 0.53-0.72, P < 0.00001) without increasing the risk of bleeding (OR 1.02, 95% CI 0.80-1.30, P = 0.89). However, prasugrel or ticagrelor pretreatment was not associated with a lower risk of mortality (OR 0.70, 95% CI 0.31-1.59, P = 0.40) and increased the risk of bleeding (OR 1.67, 95% CI 1.10-2.54, P = 0.02). CONCLUSIONS In summary, clopidogrel pretreatment was associated with significantly lower mortality, major adverse cardiovascular events, myocardial infarction and revascularization with no increase in major bleeding. However, these advantages were not observed with prasugrel or ticagrelor pretreatment.
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Affiliation(s)
- Longhui Yan
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Yan Zhou
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Zhangjie Yu
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Mengmei Xuan
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Buyun Xu
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
- *Correspondence: Fang Peng (e-mail: ), Buyun Xu (e-mail: )
| | - Fang Peng
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
- *Correspondence: Fang Peng (e-mail: ), Buyun Xu (e-mail: )
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Lang Q, Qin C, Meng W. Appropriate Timing of Coronary Artery Bypass Graft Surgery for Acute Myocardial Infarction Patients: A Meta-Analysis. Front Cardiovasc Med 2022; 9:794925. [PMID: 35419440 PMCID: PMC8995744 DOI: 10.3389/fcvm.2022.794925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/15/2022] [Indexed: 02/05/2023] Open
Abstract
Background Currently, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are commonly used in the treatment of coronary atherosclerotic heart disease. But the optimal timing for CABG after acute myocardial infarction (AMI) is still controversial. The purpose of this article was to evaluate the optimal timing for CABG in AMI. Methods We searched the PubMed, Embase, and Cochrane library databases for documents that met the requirements. The primary outcome was in-hospital mortality. The secondary outcomes were perioperative myocardial infarction (MI) incidence and cerebrovascular accident incidence. Results The search strategy produced 1,742 studies, of which 19 studies (including data from 113,984 participants) were included in our analysis. In total, 14 studies compared CABG within 24 h with CABG late 24 h after AMI and five studies compared CABG within 48 h with CABG late 48 h after AMI. The OR of in-hospital mortality between early 24 h CABG and late 24 h CABG group was 2.65 (95%CI: 1.96 to 3.58; P < 0.00001). In the undefined ST segment elevation myocardial infarction (STEMI)/non-ST segment elevation myocardial infarction (NSTEMI) subgroup, the mortality in the early 24 h CABG group (OR: 3.88; 95%CI: 2.69 to 5.60; P < 0.00001) was significantly higher than the late 24 h CABG group. Similarly, in the STEMI subgroup, the mortality in the early 24 h CABG group (OR: 2.62; 95% CI: 1.58 to 4.35; P = 0.0002) was significantly higher than that in the late 24 h CABG group. However, the mortality of the early 24 h CABG group (OR: 1.24; 95%CI: 0.83 to 1.85; P = 0.29) was not significantly different from that of the late 24 h CABG group in the NSTEMI group. The OR of in-hospital mortality between early 48 h CABG and late 48 h CABG group was 1.91 (95%CI: 1.11 to 3.29; P = 0.02). In the undefined STEMI/NSTEMI subgroup, the mortality in the early 48 h CABG group (OR: 2.84; 95%CI: 1.31 to 6.14; P < 0.00001) was higher than the late 48 h CABG group. The OR of perioperative MI and cerebrovascular accident between early CABG and late CABG group were 1.38 (95%CI: 0.41 to 4.72; P = 0.60) and 1.31 (95%CI: 0.72 to 2.39; P = 0.38), respectively. Conclusion The risk of early CABG could be higher in STEMI patients, and CABG should be delayed until 24 h later as far as possible. However, the timing of CABG does not affect mortality in NSTEMI patients. There was no statistical difference in perioperative MI and cerebrovascular accidents between early and late CABG.
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Affiliation(s)
- Qianlei Lang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chaoyi Qin
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Meng
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
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Weigel F, Nudy M, Krakowski G, Ahmed M, Foy A. Meta-Analysis of Nonrandomized Studies to Assess the Optimal Timing of Coronary Artery Bypass Grafting After Acute Myocardial Infarction. Am J Cardiol 2022; 164:44-51. [PMID: 34815058 DOI: 10.1016/j.amjcard.2021.10.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
Abstract
The optimal timing of coronary artery bypass grafting (CABG) in patients after an acute myocardial infarction (MI) is unknown. We performed a systematic review and meta-analysis of studies comparing mortality rates in patients who underwent CABG at different time intervals after acute MI. Bias assessments were completed for each study, and summary of proportions of all-cause mortality were calculated based on CABG at various time intervals after MI. A total of 22 retrospective studies, which included a total of 137,373 patients were identified. The average proportion of patients who died when CABG was performed within 6 hours of MI was 12.7%, within 6 to 24 hours of MI was 10.9%, within 1 day of MI was 9.8%, any time after 1 day of MI was 3.0%, within 7 days of MI was 5.9%, and any time after 7 days of MI was 2.7%. Interstudy heterogeneity, assessed using I2 values, showed significant heterogeneity in death rates within subgroups. Only 1 study accounted for immortal time bias, and there was a serious risk of selection bias in all other studies. Confounding was found to be a serious risk for bias in 55% of studies because of a lack of accounting for type of MI, MI severity, or other verified cardiac risk factors. The current publications comparing timing of CABG after MI is at serious risk of bias because of patient selection and confounding, with heterogeneity in both study populations and intervention time intervals.
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11
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Huo B, Hirsch GM, Doucette S, Herman CR, Gainer R, Mokhtar AT. Impact of Clopidogrel Stop Interval on Major Adverse Bleeding Events in Cardiac Surgery. CJC Open 2022; 4:12-19. [PMID: 35072023 PMCID: PMC8767124 DOI: 10.1016/j.cjco.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background Major societal guidelines recommend a 5-day stop interval before cardiac surgery for patients with acute coronary syndrome receiving clopidogrel. Yet, many such patients present with high acuity, generating surgeon inclination toward use of shorter stop intervals. Thus, this study aimed to determine the impact of the duration and timing of the interval of clopidogrel cessation on adverse bleeding events. Methods Patients who underwent cardiac surgery between 2009 and 2016 at a tertiary-care centre were included in this retrospective cohort study. Multivariable logistic regression models adjusted for clopidogrel stop interval, age, urgency of procedure, and procedure type were used to quantify the effect of clinically relevant baseline demographic characteristics on incidence of massive transfusion as well as hemorrhagic complication outcomes. Results A total of 5748 patients underwent cardiac surgery. In this cohort, 1743 patients (30.3%) received clopidogrel preoperatively, and 884 (50.7%) of these patients discontinued clopidogrel 5 days before presenting to the operating room. The administration of clopidogrel 1-2 days before surgery (odds ratio 1.97; 95% confidence interval: 1.18 to 3.29) was an independent predictor for massive transfusions and hemorrhagic complications (odds ratio 1.85; 95% confidence interval: 1.01 to 3.37). The 3-4 day group did not have an increased risk of major bleeding complications. The risk for both massive transfusions and hemorrhagic complications also increased with the urgency and complexity of surgery. Conclusion A clopidogrel stop interval of 3-4 days preoperatively was not associated with an increased risk for major bleeding complications.
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Malmberg M, Gunn J, Rautava P, Sipilä J, Kytö V. Outcome of acute myocardial infarction versus stable coronary artery disease patients treated with coronary bypass surgery. Ann Med 2021; 53:70-77. [PMID: 32875916 PMCID: PMC7877950 DOI: 10.1080/07853890.2020.1818118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/28/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To study the long-term outcome differences between acute myocardial infarction (MI) and stable coronary artery disease (CAD) patients treated with coronary artery bypass grafting (CABG). METHODS We studied retrospectively patients with MI (n = 1882) or stable CAD (n = 13117) treated with isolated CABG between 2004 and 2014. Inverse propensity probability weight adjustment for baseline features was used. Median follow-up was 7.9 years. RESULTS In-hospital mortality (8.6% vs. 1.6%; OR 5.94; p < .0001) and re-sternotomy (5.5% vs. 2.7%; OR 2.07; p < .0001) were more common in MI patients compared to stable CAD patients. Hospital surviving MI patients had higher all-cause mortality (28.2% vs. 22.2%; HR 1.37; p = .002) and MACE rate (34.4% vs. 27.4%; HR 1.22; CI 1.00-1.50; p = .049) at 10-year follow-up. Cardiovascular mortality (15.9% vs. 12.7%; HR 1.36; p = .017) and rate of new myocardial infarction (12.0% vs. 9.8%; HR 1.40; p = .034) were also higher in MI patients during follow-up. In follow-up of stabilized first-year survivors, the difference in all-cause (26.5% vs. 20.7%; HR 1.40; p = .003) and cardiovascular (14.2% vs. 11.4%; HR 1.37; p = .027) mortality continued to increase between MI and stable CAD patients. CONCLUSION MI patients have poorer short- and long-term outcomes compared to stable CAD patients after CABG and risk difference continues to increase with time. Key Messages Patients with myocardial infarction have poorer short- and long-term outcomes compared to stable coronary artery disease patients after coronary artery bypass grafting (CABG). Higher risk of death continues also in stabilized first-year myocardial infarct survivors. The importance of efficient secondary prevention and follow-up highlights in post-myocardial infarct population after CABG.
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Affiliation(s)
- Markus Malmberg
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, Turku, Finland
- Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
| | - Jussi Sipilä
- Department of Neurology, North Karelia Central Hospital, Siun Sote, Joensuu, Finland
- Department of Neurology, University of Turku, Turku, Finland
| | - Ville Kytö
- Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland
- Administative Center, Hospital District of Southwest Finland, Turku, Finland
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Wittlinger T, Schramm R, Bleiziffer S, Rudolph V, Gummert JF, Deutsch MA. Prognosis and Clinical Results after Coronary Artery Bypass Operation in Young Patients Aged <45 Years: Chances and Limitations of a New Therapy Option. Thorac Cardiovasc Surg 2021; 70:537-543. [PMID: 34808682 DOI: 10.1055/s-0041-1736229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Coronary artery bypass grafting (CABG) is the recommended type of revascularization procedure in patients with left main or three-vessel disease and is considered an alternative when percutaneous coronary intervention is not feasible. We evaluated registry data to obtain long-term outcome data.All patients ≤45 years in whom CABG was performed between 2009 and 2019 were selected from the Heart and Diabetes Center NRW, Germany. Cox regression analysis was applied to estimate the incidence risk of events after surgery.A total of 209 patients (81.8% male) were included. Mean (standard deviation) follow-up duration was 5.8 (3.1) years. The combined outcome of death, stroke, myocardial infarction, or repeated revascularization occurred in 31 patients (14.8%). Estimated mean time to event was 8.5 (standard error: 0.22) years. By the end of the follow-up period, 8 patients (3.8%) had died, among whom 2 (1.0%) died within 1 month after surgery, 1 (0.5%) within 1 year, 1 (0.5%) within 2 years, and 4 (1.9%) after 2 years.Risk factors independently associated with postsurgery events were angina pectoris CCS (Canadian Cardiovascular Society) class IV (adjusted hazard ratio [HR]: 4.954; 95% confidence interval [CI]: 1.322-18.563; p = 0.018) and STS (Society of Thoracic Surgeons) score (adjusted HR: 1.152 per scoring point; 95% CI: 1.040-1.276; p = 0.007).After performing CABG in patients ≤45 years, event-free long-term outcomes were observed in the majority of patients. Presence of angina pectoris CCS class IV and higher STS scores were independently associated with adverse postsurgery events.
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Affiliation(s)
- Thomas Wittlinger
- Department of Cardiology, Asklepios Hospital Goslar, Goslar, Germany
| | - René Schramm
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Sabine Bleiziffer
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Volker Rudolph
- Department of General and Interventional Cardiology/Angiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jan Fritz Gummert
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Marcus-André Deutsch
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
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Yau TH, Chong MH, Brigden ZM, Ngemoh D, Harky A, Bin Saeid J. The timing of surgical revascularisation in acute myocardial infarction: when should we intervene? THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 63:179-186. [PMID: 34792311 DOI: 10.23736/s0021-9509.21.11984-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Coronary artery bypass grafting (CABG) is a crucial intervention in acute myocardial infarction (AMI), particularly when AMI is not amenable for management with primary percutaneous coronary intervention (PCI). To optimise outcome in these patients, surgical teams must consider a host of predictive factors, with the most prominent being the timing of CABG. Despite numerous studies exploring timing of CABG following AMI in the past, optimal surgical timing remains controversial. The mortality rates vary with timing of CABG, but confounding factors such as age, impaired pulmonary function, renal insufficiency, and poor left ventricular function may contribute to varied outcomes reported. EVIDENCE ACQUISITON An electronic literature search of articles that discussed acute myocardial presentation and urgent in-patient or elective CABG was conducted. EVIDENCE SYNTHESIS The evidence was synthesised based on each reported article and their outcomes. CONCLUSIONS Current literature suggests multiple factors can guide CABG timing including, type of AMI at initial presentation, distinctive pathological status and patient characteristics. Thus, there is a need for large, multi-centre studies to identify optimal CABG timing in complex coronary artery disease or failed PCI in patients with AMI. Future guidelines should emphasise patient cohorts by taking their risk factors into consideration. As such, a need for greater cardiac screening methods and development of scoring systems can aid in the optimisation of CABG timing.
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Affiliation(s)
- Thomas H Yau
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ming H Chong
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Zachary M Brigden
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Dorette Ngemoh
- Medical School, St George's University of London, London, UK
| | - Amer Harky
- Department of Cardio-thoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK -
| | - Jalal Bin Saeid
- Department of Cardio-thoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Timing of coronary artery bypass grafting after acute myocardial infarction: does it influence outcomes? POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 18:27-32. [PMID: 34552641 PMCID: PMC8442093 DOI: 10.5114/kitp.2021.105184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/06/2021] [Indexed: 11/17/2022]
Abstract
Introduction The optimal timing of coronary artery bypass grafting (CABG) operations in patients with recent acute myocardial infarction (AMI) remains unclear. Aim To assess the influence of timing on post-operative outcomes in patients undergoing CABG following AMI. Material and methods In this retrospective analysis 12,224 consecutive patients undergoing CABG were included. 2477 (20.5%) patients had a history of AMI. Based on timing, patients were divided into 3 groups: those operated within 7 days of AMI; those operated after 7 days but within 1 month; and a third group operated after 1 month but within 3 months. The 3 groups were compared in terms of baseline, intra-operative, and post-operative morbidity and mortality. Multivariate analysis was carried out to assess the independent influence of timing of CABG on outcomes. Results There was no difference in terms of previous neurological events (p = 0.554), presence of carotid artery disease (p = 0.555), prevalence of hypertension (p = 0.119), diabetes (p = 0.144), hypothyroidism (p = 0.53), chronic obstructive pulmonary disease (p = 0.079), peripheral vascular disease (p = 0.771), and impaired left ventricular function (p = 0.072). On univariate analysis, mortality risk was highest between 1 week and 1 month (p = 0.003). Multivariate analysis showed that the closer the MI and CABG duration, the higher the mortality (co-efficient -0.517; p = 0.019; odds ratio = 0.596; 95% CI: 0.388-0.917). Conclusions The duration between MI and CABG has a direct influence on outcomes after CABG. While it is clear that the longer the duration between MI and CABG, the lower the mortality risk, it is however difficult to decide on an exact cut-off time frame.
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Hadaya J, Sanaiha Y, Tran Z, Downey P, Shemin RJ, Benharash P. Timing of Coronary Artery Bypass Grafting in Acute Coronary Syndrome: A National Analysis. Ann Thorac Surg 2021; 113:1482-1490. [PMID: 34126075 DOI: 10.1016/j.athoracsur.2021.05.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/23/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Timing of surgical revascularization for acute coronary syndrome (ACS) remains debated. We assessed the impact of timing to CABG on mortality and resource utilization in a national cohort. METHODS Adults admitted for ACS in the 2009-2018 National Inpatient Sample were grouped by time from coronary angiography to CABG (Δt): 0, 1-3, 4-7, and >7 days. Generalized linear models were fit to evaluate associations between Δt and in-hospital mortality and hospitalization costs. Timing and mortality of CABG for ACS was compared between high-performing hospitals (below the median risk adjusted mortality for all CABG and valve operations) and others. RESULTS Of 444,065 patients, time to CABG was Δt=0 in 12.3%, Δt=1-3 in 57.3%, Δt=4-7 in 26.3%, and Δt>7 in 4.2%. Risk-adjusted mortality was greatest at Δt=0 (4.5%, 95% confidence interval, CI, 4.1-4.9) and Δt>7 (4.0%, 95% CI 3.4-4.7), but similar for operations performed at Δt=1-3 (1.8%, 95% CI 1.7-1.9) and Δt=4-7 (2.1%, 95% CI 1.9-2.3). Compared to Δt=1-3, hospitalization costs were greater by $6,400 (95% CI 5,900-6,900) for Δt=4-7 and $21,200 (95% CI 19,800-22,600) for Δt>7. High-performing hospitals had similar time to CABG as others (2 vs 2 days, p=0.17), but lower mortality (0.9% vs 3.3%, p<0.001). CONCLUSIONS Revascularization on day 1-3 and 4-7 led to comparable in-hospital mortality, with greater rates on day 0 and after day 7. Costs were greater for revascularization at day 4-7 compared to day 1-3. These findings support the reduction of time to revascularization to 1-3 days when deemed clinically appropriate and feasible.
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Affiliation(s)
- Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peter Downey
- Department of Cardiovascular and Thoracic Surgery, University of Kansas Health System, Kansas City, Kansas
| | - Richard J Shemin
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California.
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Timing of coronary artery bypass grafting after acute myocardial infarction may not influence mortality and readmissions. J Thorac Cardiovasc Surg 2021; 161:2056-2064.e4. [DOI: 10.1016/j.jtcvs.2019.11.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 11/06/2019] [Accepted: 11/24/2019] [Indexed: 11/17/2022]
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Hess NR, Sultan I, Wang Y, Thoma FW, Kilic A. Preoperative troponin levels and outcomes of coronary surgery following myocardial infarction. J Card Surg 2021; 36:2429-2439. [PMID: 33855738 DOI: 10.1111/jocs.15557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/19/2021] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study evaluates the impact of peak preoperative troponin level on outcomes of coronary artery bypass grafting (CABG) for non-ST-elevation myocardial infarction (NSTEMI). METHODS This was a retrospective review of patients undergoing isolated CABG from 2011 to 2018 with the presentation of NSTEMI. Patients were stratified into low- and high-risk groups based on median preoperative peak troponin (1.95 ng/dl). Major adverse cardiac and cerebrovascular events (MACCE) and mortality were compared. Multivariable analysis was performed to model risk factors for MACCE and mortality. RESULTS This study included 1211 patients, 607 low-risk (≤1.95 ng/dl) and 604 high-risk (>1.95 ng/dl). Patients were well-matched with respect to age and comorbidity. High-risk patients had lower median preoperative ejection fraction (46.5% [interquartile range {IQR}: 35.0%-55.0%] vs. 53.0% [IQR: 40.0%-58.0%]) and higher incidence of preoperative intra-aortic balloon pump (15.9% vs. 8.73%). Intensive care unit and hospital length of stay were longer in the high-risk group, but increasing troponin level was not associated with prolonged intensive care or hospital length of stay (>4 and >14 days, respectively) after risk adjustment. Postoperative complications and 30-day, 1- and 5-year rates of both MACCE and survival were similar between groups. Peak troponin greater than 1.95 ng/dl was not associated with increased hazards for MACCE, mortality, or readmission in multivariable modeling. In subanalysis, neither increasing troponin as a continuous variable nor peak troponin greater than 10.00 ng/ml were associated with increased hazards for these outcomes. CONCLUSIONS Preoperative troponin levels do not appear to be predictive of short- or long-term outcomes following CABG, and clinical decisions regarding surgical revascularization should not be dictated by these measurements.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd W Thoma
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Nishonov AB, Tarasov RS, Ivanov SV, Barbarash LS. [Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: in-hospital outcomes. Part 2]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:151-157. [PMID: 33825742 DOI: 10.33529/angio2021104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To assess in-hospital outcomes of coronary artery bypass grafting in patients with acute coronary syndrome, depending on the presence or absence of myocardial infarction. PATIENTS AND METHODS Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and subjected to coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction, who underwent surgery at an average of 16 (11; 20) days after manifestation of the clinical signs of myocardial infarction. The endpoints of the study were major adverse cardiovascular events during the in-hospital period: death, myocardial infarction, acute cerebral circulation impairment/transitory ischaemic attack, repeat revascularization, septic complications, multiple organ failure syndrome, wound infectious complications, requirement for repeated surgical debridement, remediastinotomy due to haemorrhage, the frequency of extracorporeal membrane oxygenation and renal replacement therapy. RESULTS The mortality rate in the compared groups was similar: 3% (n=3) and 3% (n=2), respectively. Perioperative myocardial infarction occurred in 1 (1%) patient of the first group, with no cases of this complication observed in the second group. The frequency of reoperations due to haemorrhage in the early postoperative period in the group of unstable angina pectoris amounted to 3% (n=3) and was associated with administration of dual antithrombotic therapy, with no cases of this complication in the group of myocardial infarction. Wound complication in the second group were observed in 7.6% (n=5) and in the first group in 4% (n=4) (p=0.33). The differences turned out to be statistically insignificant for such postoperative complications as multiple organ failure syndrome, requirement for repeated surgical debridement, renal replacement therapy, and extracorporeal membrane oxygenation. The residual SYNTAX Score in the group of myocardial infarction amounted to 2.3±2.8, whereas in the group of unstable angina pectoris to 2.3±3, thus suggesting complete revascularization in the total sample of patients with acute coronary syndrome. The average length of hospital stay (including the postoperative period) in the first group amounted to 26.3±6.6 days and in the second group to 27.4±7.2 days (p=0.53). The postoperative bed-day in the group with unstable angina pectoris was 12.6±3.2 and in the myocardial infarction group - 14.9±5.3 (p=0.06). CONCLUSION The obtained in-hospital outcomes suggest that coronary artery bypass grafting may be an efficient and safe method of complete revascularization for patients with non-ST-elevation acute coronary syndrome, including that resulting in myocardial infarction, performed averagely on day 16 (11; 20) after the onset of clinical manifestations of myocardial infarction.
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Affiliation(s)
- A B Nishonov
- Cardiosurgical Department, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - R S Tarasov
- Cardiosurgical Department, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - S V Ivanov
- Cardiosurgical Department, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - L S Barbarash
- Cardiosurgical Department, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
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Ticagrelor Utilization in Patients With Non-ST Elevation Acute Coronary Syndromes in Romania. Am J Ther 2021; 28:e271-e283. [PMID: 33852478 DOI: 10.1097/mjt.0000000000001358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) represents a major tool of non-ST elevation acute coronary syndrome (NSTE-ACS) management. The real-world usage of potent P2Y12 inhibitors within DAPT in middle-income countries is poorly described. STUDY QUESTION To assess the factors that influence P2Y12 inhibitor choice at discharge in invasively managed NSTE-ACS patients, without an indication for oral anticoagulation, treated across Romania. STUDY DESIGN The Romanian National NSTE-ACS Registry allows the consecutive enrollment of NSTE-ACS patients admitted in 11 (of 24) interventional centers reimbursed from public funds. MEASURES AND OUTCOMES NSTE-ACS patients that received DAPT at discharge were identified. Deceased patients, those with an indication for oral anticoagulation or not receiving DAPT at discharge, were excluded. P2Y12 inhibitor choice was analyzed based on demographic, clinical, and invasive management characteristics. RESULTS One thousand fifty (63 ± 10 years, 73% male) of 1418 patients enrolled between 2016 and 2019 were analyzed. The P2Y12 inhibitor pretreatment rate was 90%. Obstructive coronary artery disease was found in 95.3% of patients. 84.6% underwent percutaneous coronary interventions (PCIs). Single vessel PCI was reported in 84% of PCI patients. The clopidogrel usage rate was 49.6%, ticagrelor 50.0%, and prasugrel 0.4%. Overall, higher ticagrelor usage was associated with: non-ST elevation myocardial infarction (P 0.035), age below 65 (P < 0.001), prior treatment with ticagrelor (P < 0.001), PCI during admission (P < 0.001), and its full 12-month reimbursement (since November 2017). Reimbursement increased the use of ticagrelor from 23.7% in 2016-2017 to 56.9% in 2018-2019 (P < 0.001). In PCI patients, ticagrelor use was associated with PCI with stenting (P 0.016) and multivessel PCI (0.013). CONCLUSIONS DAPT, P2Y12 inhibitor pretreatment, and single vessel PCI are the standards of care in invasively managed NSTE-ACS patients in Romania. Besides the clinical and invasive characteristics that favor its use, the full reimbursement of ticagrelor introduced in November 2017 doubled its yearly usage.
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Mokhtar AT, Tennankore K, Doucette S, Herman CR. Predicting acute kidney injury following nonemergent cardiac surgery: A preoperative scorecard. J Card Surg 2021; 36:2204-2212. [PMID: 33738864 DOI: 10.1111/jocs.15503] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the predictors of postoperative acute kidney injury (AKI) following nonemergent cardiac surgery among patients with variable preoperative estimated glomerular filtration rate (eGFR) levels. METHODS A retrospective study of patients who underwent elective or in-hospital cardiac surgical procedures was performed between January 2006 and November 2015. The procedures included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), or combined CABG and AVR. The primary outcome AKI (any stage) following nonemergent cardiac surgery utilizing the 2012 Kidney Disease-Improving Global Outcomes (KDIGO) criteria. Patients were categorized based on the following renal outcomes: mild AKI, severe AKI (KDIGO stage 2 or 3), and postoperative dialysis. Patients with G5 preoperative kidney function (including dialysis patients) were excluded. RESULTS A total of 6675 patients were included in our study. The mean age was 66.8 years (SD ± 10.4), with 76.3% being males. A total of 4487 patients had normal or mildly decreased eGFR (G1 or G2) preoperatively (67.2%), while 1960 patients were in the G3 category (29.4%). Only 228 patients (3.4%) had G4 renal function. A total of 1453 (21.7%) patients experienced postoperative AKI. The need for postoperative dialysis occurred in 3.2% of the AKI subgroup. In-hospital mortality was higher among the AKI subgroup (7.2% vs. 0.5%; p < .0001). In an adjusted model, a lower preoperative eGFR category was the strongest predictor of AKI. A practical scorecard for the preoperative estimation of severe AKI for nonemergent cardiac procedures incorporating these parameters was developed. CONCLUSIONS Preoperative eGFR is the strongest predictor of postoperative AKI in individuals undergoing nonemergent cardiac surgery. A practical scorecard incorporating preoperative predictors of AKI may allow informed decision-making and predict AKI following nonemergent cardiac surgery.
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Affiliation(s)
- Ahmed T Mokhtar
- Department of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Medicine, Division of Cardiology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Karthik Tennankore
- Department of Medicine, Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Steve Doucette
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Christine R Herman
- Department of Surgery, Division of Cardiac and Vascular Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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22
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Uygur B, Demir AR, Guner A, Iyigun T, Uzun N, Celik O. Utility of logistic clinical SYNTAX score in prediction of in-hospital mortality in ST-elevation myocardial infarction patients undergoing emergent coronary artery bypass graft surgery. J Card Surg 2021; 36:857-863. [PMID: 33415773 DOI: 10.1111/jocs.15308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 11/30/2022]
Abstract
AIM The logistic clinical SYNTAX score (log CSS) is a combined risk scoring system including clinical and anatomic parameters; it has been found to be effective for the prediction of mortality in patients with ST-elevation myocardial infarction (STEMI). Coronary artery bypass grafting (CABG) in the primary treatment of acute myocardial infarction is still debated. In the present study, we aimed to evaluate the utility of log CSS to stratify the risk of in-hospital mortality in acute STEMI patients undergoing emergent CABG for primary revascularization. METHOD In total, 88 consecutive patients with acute STEMI, who did not qualify for primary percutaneous coronary intervention and required emergent CABG were included in our study. Nine of 88 patients died during hospitalization. The study population was divided into two groups as in-hospital survivors and non-survivors. Log CSS and SYNTAX score (SS) were calculated for both groups and two groups were compared in terms of demographics, preoperative, intraoperative, postoperative characteristics, SS and log CSS. RESULTS Log CSS was found to be an independent predictor of in-hospital mortality, log CSS > 10.5 had 89% sensitivity, 81% specificity (area under the curve: 0.927; 95% confidence interval: 0.855-0.993). Moreover, peak troponin level was an independent predictor of in-hospital mortality. Glucose level, cardiopulmonary resuscitation before operation, glomerular filtration rate, left ventricular ejection fraction, and Killip class were significantly associated with in-hospital mortality. CONCLUSION Log CSS may improve the accuracy of risk assessment in patients who are undergoing emergent CABG for primary revascularization of STEMI.
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Affiliation(s)
- Begum Uygur
- Cardiology Department, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Ali R Demir
- Cardiology Department, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Ahmet Guner
- Cardiology Department, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Taner Iyigun
- Cardiovascular Surgery Department, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Nedim Uzun
- Emergency Department, Gaziosmanpasa Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Omer Celik
- Cardiology Department, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Science, Istanbul, Turkey
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23
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Nishonov AB, Tarasov RS, Ivanov SV, Barbarash LS. [Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: analysis of perioperative factors. Part 1]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:132-140. [PMID: 33332315 DOI: 10.33529/angio2020407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM The purpose of this study was to assess the perioperative clinical, demographic and anatomo-angiographic factors in patients presenting with non-ST-segment elevation acute coronary syndrome and being candidates for coronary artery bypass grafting, depending on the presence or absence of myocardial infarction. PATIENTS AND METHODS Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and recommended by the cardiosurgical team to undergo coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction. A lethal outcome occurred in 2 (3%) Group Two patients prior to revascularization, hence they were not included into the analysis comparing the results of surgery in both groups, however these data were taken into consideration, being analysed separately. RESULTS The group of patients with myocardial infarction appeared to include significantly more female patients (20 (30.3%) versus 15 (15.3%) in the group of patients with unstable angina pectoris, p=0.02). However, by such parameters as the average age, left ventricular ejection fraction, and the frequency of diabetes mellitus the compared groups did not differ. The group with myocardial infarction was characterised by a severe clinico-angiographic status: more frequently encountered was stage II obesity (3%, n=3 in the first group and 10.6% n=7 in the second group, p=0.04). On the whole, the majority of patients were at intermediate and high risk (44.7% in the group with unstable angina pectoris versus 81.8% in the group of myocardial infarction, p<0.05). Group Two patients significantly more often presented with three-vessel lesions of the coronary bed (40 (40.8%) and 39 (59%), p=0.02). The level of low-density lipoproteins appeared to be significantly higher in patients with myocardial infarction (3.3±1 mmol/l and 2.9±0.9, p=0.04). In the same group more often encountered were peripheral artery lesions (28 (21%) and 12 (11.3%), p=0.04). In its turn, in the group of unstable angina pectoris, there were significantly more patients having received dual antithrombotic therapy prior to surgery (44 (44.9%) and 17 (25%), p=0.01). Approximately half of the patients in the first group (53%, n=52) had a history of myocardial infarction (p=0.001). CONCLUSION The obtained findings suggested that amongst the patients with non-ST-elevation acute coronary syndrome resulting in myocardial infarction prevailing were those of female gender, with obesity, as a consequence, hyperholesterolaemia and triple-vessel disease. At the same time, postinfarction cardiosclerosis, renal dysfunction, and haemodynamically significant lesions of lower-extremity arteries were encountered in the group of unstable angina pectoris.
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Affiliation(s)
- A B Nishonov
- Cardiosurgical Department, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - R S Tarasov
- Cardiosurgical Department, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - S V Ivanov
- Cardiosurgical Department, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - L S Barbarash
- Cardiosurgical Department, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
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24
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Liakopoulos OJ, Slottosch I, Wendt D, Welp H, Schiller W, Martens S, Choi YH, Welz A, Pisarenko J, Neuhäuser M, Jakob H, Ruhparwar A, Wahlers T, Thielmann M. Surgical revascularization for acute coronary syndromes: a report from the North Rhine-Westphalia surgical myocardial infarction registry. Eur J Cardiothorac Surg 2020; 58:1137-1144. [PMID: 33011789 DOI: 10.1093/ejcts/ezaa260] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/29/2020] [Accepted: 06/11/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this was to analyse current outcomes in patients referred to coronary artery bypass grafting (CABG) for acute coronary syndromes (ACSs), including ST-elevation or non-ST-elevation ACS (non-ST-segment elevation myocardial infarction) or unstable angina. METHODS Patients (n = 2432) undergoing CABG for ACS between January 2010 and December 2017 were prospectively entered into a surgical myocardial infarction registry in North Rhine-Westphalia, Germany. Key end points were in-hospital all-cause mortality (IHM) and major adverse cardio-cerebral events (MACCE). Predictors for IHM and MACCE were analysed by multivariable logistic regression. RESULTS Patients (78% males) were referred for CABG for unstable angina (25%), non-ST-segment elevation myocardial infarction (50%), and ST-segment elevation myocardial infarction (25%). The mean patient age was 68 ± 11 years, logistic EuroSCORE was 19 ± 18% and three-vessel and left main stem diseases were diagnosed in 81% and 45% of patients, respectively. On-pump CABG with cardiac arrest or beating heart was performed in 92% and 2%, respectively, with only 6% off-pump surgery and 6% multiple arterial revascularization (3.1 ± 1.0 grafts, 93% left internal thoracic artery). Emergency CABG was performed in 23% of patients (42% in ST-segment elevation myocardial infarction; P < 0.001). The total IHM and MACCE rates were 8.1% and 17.5% and were highest in ST-segment elevation myocardial infarction patients with 12.6% and 28.5%, respectively (P < 0.001). Key predictors for IHM and MACCE were female gender, elevated troponin, left ventricular ejection fraction, inotropic support, logistic EuroSCORE, cardiopulmonary bypass and aortic clamp time and the need for emergency CABG. CONCLUSIONS Surgical myocardial revascularization in patients with ACS is still linked to substantial in-hospital mortality. Emergency CABG for patients with ACS was associated with poorer outcomes.
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Affiliation(s)
- Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ingo Slottosch
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Hendryk Welp
- Department of Cardiac Surgery, University Hospital Münster, Münster, Germany
| | | | - Sven Martens
- Department of Cardiac Surgery, University Hospital Münster, Münster, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.,Department of Cardiac Surgery, Campus Kerckhoff, University of Giessen, Giessen, Germany
| | - Armin Welz
- Department of Cardiac Surgery, University of Bonn, Bonn, Germany
| | - Julia Pisarenko
- Department of Mathematics and Technology, Koblenz University of Applied Science, Remagen, Germany.,Institute of Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Markus Neuhäuser
- Department of Mathematics and Technology, Koblenz University of Applied Science, Remagen, Germany.,Institute of Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
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Malmberg M, Sipilä J, Rautava P, Gunn J, Kytö V. Outcomes After ST-Segment Versus Non-ST-Segment Elevation Myocardial Infarction Revascularized by Coronary Artery Bypass Grafting. Am J Cardiol 2020; 135:17-23. [PMID: 32871111 DOI: 10.1016/j.amjcard.2020.08.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 01/28/2023]
Abstract
The objectives of this study were to investigate the outcome differences between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients treated with coronary artery bypass grafting surgery (CABG). We conducted a multicenter, retrospective cohort follow-up study of consecutive patients with STEMI (surgery ≤48 hours of admission; n = 348) or NSTEMI (n = 1,160) revascularized with first-time isolated CABG in Finland using nationwide registries (median age 68 years, 24% women). The short- and long-term (10-year) outcomes were studied with inverse propensity probability weight adjustment for baseline features. The median follow-up was 5.2 years. In-hospital mortality (11.4% vs 5.3%; adj. odds ratio [OR] 2.27; confidence interval [CI] 1.41 to 3.66; p = 0.001) and re-sternotomy rates (6.9% vs 3.5%; adj. OR 2.07; CI 1.22 to 3.51; p = 0.007) were higher in STEMI patients. Long-term all-cause mortality did not differ between STEMI and NSTEMI patients among all operated patients (30.2% vs 28.3%; adj. HR 1.30; CI 0.97 to 1.75; p = 0.080) or hospital survivors (21.6 vs 24.3%; HR 0.93; CI 0.64 to 1.36; p = 0.713). Occurrence of major adverse cardiovascular event in hospital survivors within 10 years was 34.7% in STEMI versus 29.6% in NSTEMI (adj. HR 1.24; CI 0.88 to 1.76; p = 0.220). Occurrences of cardiovascular death (14.6% vs 14.4%; p = 0.773), myocardial infarction (MI; 15.2% vs 10.3%; p = 0.203), and stroke (10.8% vs 14.8%; p = 0.242) were also comparable. In conclusion, patients with STEMI have poorer short-term outcome compared to NSTEMI patients after revascularization by CABG, but the long-term outcomes are comparable regardless of MI type. Thus, both short- and long-term risks should be considered when evaluating patient´s for CABG eligibility by MI type.
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Affiliation(s)
- Markus Malmberg
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
| | - Jussi Sipilä
- Department of Neurology, North Karelia Central Hospital, Siun Sote, Joensuu, Finland; Department of Neurology, University of Turku, Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, Turku, Finland; Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland; Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland; Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland; Administative Center, Hospital District of Southwest Finland, Turku, Finland
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26
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Beller JP, Teman NR. Reply to Bernard. Eur J Cardiothorac Surg 2020; 58:1103-1104. [PMID: 32728729 DOI: 10.1093/ejcts/ezaa202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jared P Beller
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Abstract
PURPOSE OF REVIEW The use of coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS) has markedly declined during the past decade, with an increase in the use of percutaneous coronary intervention (PCI). However, long-term data continues to show survival advantages for patients undergoing CABG over PCI. We describe the current indications for and outcomes of CABG in patients who present with ACS. RECENT FINDINGS Real-world studies demonstrate better long-term outcomes with CABG than with PCI after NSTE-ACS. Staged CABG after culprit-vessel PCI for STEMI is also a feasible option in certain patients. In patients presenting with ACS and cardiogenic shock who are treated with CABG, the use of mechanical circulatory support has produced a limited but significant reduction in mortality. The optimal revascularization strategy after ACS depends on many variables. The pre-eminent factor in selecting the best mode of revascularization and improving outcomes is careful patient selection based on deliberation by an interdisciplinary heart team.
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Affiliation(s)
- Douglas Farmer
- Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA. .,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA. .,Division of Cardiothoracic Surgery, Michael E. DeBakey VA Medical Center, Houston, TX, USA.
| | - Ernesto Jimenez
- Department of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Division of Cardiothoracic Surgery, Michael E. DeBakey VA Medical Center, Houston, TX, USA
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28
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Liakopoulos OJ, Schlachtenberger G, Wendt D, Choi YH, Slottosch I, Welp H, Schiller W, Martens S, Welz A, Neuhäuser M, Jakob H, Wahlers T, Thielmann M. Early Clinical Outcomes of Surgical Myocardial Revascularization for Acute Coronary Syndromes Complicated by Cardiogenic Shock: A Report From the North-Rhine-Westphalia Surgical Myocardial Infarction Registry. J Am Heart Assoc 2020; 8:e012049. [PMID: 31070076 PMCID: PMC6585325 DOI: 10.1161/jaha.119.012049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock (CS) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) and ST‐segment–elevation myocardial infarction (STEMI). Methods and Results Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in‐hospital mortality (IHM) and major adverse cardiocerebral events (MACCEs). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI (P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On‐pump surgery with cardioplegia was the preferred surgical technique in CS. IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI (IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score. Conclusions Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.
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Affiliation(s)
- Oliver J Liakopoulos
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - G Schlachtenberger
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - Daniel Wendt
- 2 Department of Thoracic and Cardiovascular Surgery West German Heart Center University of Duisburg-Essen Essen Germany
| | - Yeong-Hoon Choi
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - Ingo Slottosch
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - Henryk Welp
- 4 Department of Cardiac Surgery University Hospital Münster Münster Germany
| | | | - Sven Martens
- 4 Department of Cardiac Surgery University Hospital Münster Münster Germany
| | - Armin Welz
- 5 Department of Cardiac Surgery University of Bonn Germany
| | - Markus Neuhäuser
- 3 Institute of Medical Computer Science, Biometry and Epidemiology University of Duisburg-Essen Essen Germany.,6 Department of Mathematics and Technique Koblenz University of Applied Science Remagen Germany
| | - Heinz Jakob
- 2 Department of Thoracic and Cardiovascular Surgery West German Heart Center University of Duisburg-Essen Essen Germany
| | - Thorsten Wahlers
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - Matthias Thielmann
- 2 Department of Thoracic and Cardiovascular Surgery West German Heart Center University of Duisburg-Essen Essen Germany
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Morone EJ, Barker SJ, Martinez Licha CR, Timsina LR, Namburi N, Milward JB, Everett JE, Corvera JS, Beckman DJ, Hess PJ, Lee LS. Impact of troponin I level on coronary artery bypass grafting outcomes. J Card Surg 2020; 35:2704-2709. [PMID: 32720357 DOI: 10.1111/jocs.14889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/17/2020] [Accepted: 07/14/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The effect of preoperative cardiac troponin level on outcomes after coronary artery bypass grafting (CABG) is unclear. We investigated the impact of preoperative cardiac troponin I (cTnI) level as well as the time interval between maximum cTnI and surgery on CABG outcomes. METHODS All patients who underwent isolated CABG at our institution between 2009 and 2016 and had preoperative cTnI level available were identified using our Society of Thoracic Surgeons registry. Receiver operating characteristic (ROC) analysis was performed to identify a cTnI threshold level. Subjects were divided into groups based on this value and outcomes compared. RESULTS A total of 608 patients were included. ROC analysis identified 5.74 µg/dL as the threshold value associated with worse postoperative outcomes. Patients with peak cTnI >5.74 µg/dL underwent CABG approximately 1 day later, had twice the risk of adverse postoperative events, and had 2.8 day longer postoperative length of stay than those with peak cTnI ≤5.74 µg/dL. cTnI level was not associated with mortality or 30-day readmission. Time interval between peak cTnI and surgery did not affect outcomes. CONCLUSION Elevated preoperative cTnI level beyond a certain threshold value is associated with adverse postoperative outcomes but is not a marker for increased mortality. Time from peak cTnI does not affect postoperative outcomes or mortality and may not need to be considered when deciding timing of CABG.
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Affiliation(s)
- Emma J Morone
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shawn J Barker
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carlos R Martinez Licha
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lava R Timsina
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Niharika Namburi
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - James B Milward
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey E Everett
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joel S Corvera
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Daniel J Beckman
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Philip J Hess
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lawrence S Lee
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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30
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Risk of Ischemic Stroke After Acute Myocardial Infarction in Patients Undergoing Coronary Artery Bypass Graft Surgery. Sci Rep 2020; 10:3831. [PMID: 32123285 PMCID: PMC7052208 DOI: 10.1038/s41598-020-60854-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 02/03/2020] [Indexed: 11/16/2022] Open
Abstract
Only sparse epidemiological data are available regarding the risk of ischemic stroke (IS) after coronary artery bypass surgery (CABG). Here we aimed to describe the incidence and predictors of IS associated with CABG performed after acute myocardial infarction (AMI), as well as trends over time. We analyzed data for 248,925 unselected AMI patients. We separately analyzed groups of patients who underwent CABG early or late after the index infarction. IS incidence rates per year at risk were 15.8% (95% confidence interval, 14.5–17.1) and 10.9% (10.6–11.2), respectively, among patients with and without CABG in the early cohort, and 4.0% (3.5–4.5) and 2.3% (2.2–2.3), respectively, among patients with and without CABG in the late cohort. Predictors of post-AMI IS included prior IS, CABG, prior atrial fibrillation, prior hemorrhagic stroke, heart failure during hospitalization, older age, diabetes mellitus, and hypertension. Reduced IS risk was associated with use of statins and P2Y12 inhibitors. IS incidence markedly decreased among patients who did not undergo CABG, while no such reduction over time occurred among those who underwent CABG. This emphasizes the need to optimize modifiable risk factors and to consistently use treatments that may reduce IS risk among CABG patients.
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Bhattacharyya S, Oo A. Timing of surgery after secondary embolic events in infective endocarditis. Ann Cardiothorac Surg 2019; 8:688-690. [PMID: 31832363 DOI: 10.21037/acs.2019.05.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sanjeev Bhattacharyya
- Heart Valve Clinic, St Bartholomew's Hospital, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK.,Institute of Cardiovascular Sciences, UCL, London, UK
| | - Aung Oo
- William Harvey Research Institute, Queen Mary University of London, London, UK.,Department of Cardiovascular Surgery, St Bartholomew's Hospital, London, UK
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Mokhtar AT, Baghaffar A, Jackson SD, Horne D. When is the optimal time to discontinue clopidogrel before in-hospital coronary bypass surgery? A closer look at the current literature. J Card Surg 2019; 35:413-421. [PMID: 31803992 DOI: 10.1111/jocs.14371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clopidogrel and other P2Y12 inhibitors have become the standard of care among patients presenting with acute coronary syndromes. A substantial proportion of these patients require surgical revascularization during index hospitalization. HYPOTHESIS Guidelines recommend a 5-day waiting period off clopidogrel before coronary artery bypass grafting (CABG) to reduce hemorrhagic complications. These recommendations are not routinely followed in clinical practice, while recent studies also propose shorter waiting periods off clopidogrel for patients awaiting in-hospital CABG. METHODS A preliminary PubMed search was conducted using the following MeSH terms under the publication type "Hemorrhage:" "Clopidogrel," AND "Coronary Artery Bypass." Relevant studies and guidelines were then reviewed and selected based on a predetermined criteria. Studies that formulated the current recommendations for stopping clopidogrel preoperative to CABG are discussed in detail this review. RESULTS A comprehensive review of recent evidence illustrates mixed bleeding and transfusion outcomes among CABG patients with preoperative exposure to clopidogrel in less than 5 days. CONCLUSIONS The optimal discontinuation time of clopidogrel before CABG is still poorly defined. The recommendation of a 5-day washout period for clopidogrel should be reconsidered to be on par with current clinical practice.
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Affiliation(s)
- Ahmed T Mokhtar
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdullah Baghaffar
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Simon D Jackson
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Horne
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Park J, Lee SH, Min JJ, Lee JH, Kwon JH, Lee JE, Choi JH, Lee YT, Kim WS, Park M, Jang JS, Lee SM. Association between high-sensitivity cardiac troponin I measured at emergency department and complications of emergency coronary artery bypass grafting. Sci Rep 2019; 9:16933. [PMID: 31729415 PMCID: PMC6858436 DOI: 10.1038/s41598-019-53047-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 10/23/2019] [Indexed: 12/27/2022] Open
Abstract
High-sensitivity cardiac troponin I (hs-cTnI) is a widely used biomarker to identify ischemic chest pain in the Emergency Department (ED), but the clinical impact on emergency coronary artery bypass grafting (eCABG) remains undetermined. We aimed to evaluate the clinical impact of hs-cTnI measured at the ED by comparing outcomes of eCABG in patients with non–ST-segment–elevation acute coronary syndrome (NSTE-ACS) which comprises unstable angina (UA) and non–ST-segment–elevation myocardial infarction (NSTEMI). From January 2012 to March 2016, 242 patients undergoing eCABG were grouped according to serum hs-cTnI level in the ED. The primary endpoint was major cardiovascular cerebral event (MACCE) defined as a composite of all-cause death, myocardial infarction, repeat revascularization, and stroke. The incidence of each MACCE composite, in addition to postoperative complications such as acute kidney injury, reoperation, atrial fibrillation, and hospital stay duration were also compared. Patients were divided into two groups: UA [<0.04 ng/mL, n = 102] and NSTEMI [≥0.04 ng/mL, n = 140]. The incidence of MACCE did not differ between the two groups. Postoperative acute kidney injury was more frequent in the NSTEMI group after adjusting for confounding factors (6.9% vs. 23.6%; odds ratio, 2.76; 95% confidence interval, 1.09–6.99; p-value = 0.032). In-hospital stay was also longer in the NSTEMI group (9.0 days vs. 15.4 days, p-value = 0.008). ECABG for UA and NSTEMI patients showed comparable outcomes, but hs-cTnI elevation at the ED may be associated with immediate postoperative complications.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ja Eun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myungsoo Park
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Ji Su Jang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kangwon National University, Gangwondaehak-gil, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Sangmin Maria Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Rojas SV, Trinh-Adams ML, Uribarri A, Fleissner F, Iablonskii P, Rojas-Hernandez S, Ricklefs M, Martens A, Rümke S, Warnecke G, Cebotari S, Haverich A, Ismail I. Early surgical myocardial revascularization in non-ST-segment elevation acute coronary syndrome. J Thorac Dis 2019; 11:4444-4452. [PMID: 31903232 DOI: 10.21037/jtd.2019.11.08] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background In non-ST-elevation myocardial infarction (NSTEMI) there is no consensus regarding optimal time point for coronary artery bypass grafting (CABG). Recent findings suggest that long-term outcomes are improved in early-revascularized NSTEMI patients. However, it has been stated that early surgery is associated to increased operative risk. In this study, we wanted to elucidate if early CABG in non-ST-elevation acute coronary syndrome can be performed safely. Methods We performed a monocentric-prospective observational study within a 2-year interval. A total of 217 consecutive patients (41 female, age 68.9±10.2, ES II 6.62±8.56) developed NSTEMI and underwent CABG. Patients were divided into two groups according to the time point of coronary artery bypass after symptom onset (group A: <72 h; group B: >72 h). Endpoints included 6-month mortality and incidence of MACE (death, stroke or re-infarction). Results There were no differences regarding mortality between both groups (30 days: group A 2.4% vs. group B 3.7%; P=0.592; 6 months: 8.4% vs. 6.0%; P=0.487). Incidence of MACE in the 6-month follow-up was also similar in both groups (group A: 9.6% vs. 9.7%, P=0.982). Regression analysis revealed as independent risk factors for mortality in the entire cohort ES II OR 1.045 (95% CI: 1.004-1.088). ES II remained an independent prognostic factor in group A OR 1.043 (95% CI: 1.003-1.086) and group B OR 1.032 (95% CI: 1.001-1.063). Conclusions Early revascularized patients showed a higher level of illness. However, results of early CABG were comparable to those following delayed revascularization. Moreover, EuroSCORE II was determined as independent risk factors for mortality.
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Affiliation(s)
- Sebastian V Rojas
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Mai Linh Trinh-Adams
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Aitor Uribarri
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Department of Cardiology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Felix Fleissner
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Pavel Iablonskii
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Sara Rojas-Hernandez
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Marcel Ricklefs
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Stefan Rümke
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Issam Ismail
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Abstract
PURPOSE OF REVIEW Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics. RECENT FINDINGS The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient's clinical characteristics as well as the complexity of the coronary anatomy.
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Affiliation(s)
- Bennet George
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA
| | - Khaled M Ziada
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA.
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36
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Godoy LC, Lawler PR, Farkouh ME, Hersen B, Nicolau JC, Rao V. Urgent Revascularization Strategies in Patients With Diabetes Mellitus and Acute Coronary Syndrome. Can J Cardiol 2019; 35:993-1001. [PMID: 31376910 DOI: 10.1016/j.cjca.2019.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 02/01/2023] Open
Abstract
The prevalence of diabetes mellitus (DM) is rising globally and in Canada. Besides being a risk factor for the development of coronary artery disease, DM is also a marker of poor prognosis in patients with acute coronary syndrome (ACS), increasing the risks for ischemic and bleeding complications. Patients with DM have a high prevalence of multivessel coronary artery disease (MVD) and robust evidence has supported coronary artery bypass surgery (CABG) as the optimal revascularization strategy in the setting of stable ischemic heart disease. In the acute scenario, particularly in patients with non-ST-segment elevation (NSTE) ACS (NSTE-ACS), there are many uncertainties regarding the best revascularization strategy. Most guidelines suggest an invasive and timely approach (that is, performing coronary catheterization within 72 hours after the onset of the NSTE-ACS) and make recommendations about choosing between percutaneous coronary intervention (PCI) or CABG on the basis of data for patients with stable ischemic heart disease. Recent observational and subgroup analyses suggest that CABG might be the preferential method of revascularization for patients with DM and MVD also in the NSTE-ACS setting; however, dedicated randomized clinical trials are lacking. Finally, in patients who present with an ST-segment elevation myocardial infarction, the initial revascularization method of choice is generally PCI, instead of fibrinolysis or CABG, and DM status most often does not influence this decision. The management of residual MVD after primary PCI for ST-segment elevation myocardial infarction, however, remains controversial.
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Affiliation(s)
- Lucas C Godoy
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada; Instituto do Coracao (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Patrick R Lawler
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - José C Nicolau
- Instituto do Coracao (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Vivek Rao
- Peter Munk Cardiac Centre and Toronto General Research Institute, Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Neverova YN, Tarasov RS, Nagirnyak OA. Main predictors of in-hospital adverse outcomes in non-ST elevation acute coronary syndrome patients with multivessel disease. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2018. [DOI: 10.15829/1728-8800-2018-4-19-25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To evaluate the range of risk factors associated with adverse cardiovascular events onset in hospital period of follow-up in patients with non-ST elevation acute coronary syndrome (NSTEACS) with multivessel disease (MD).Material and methods. To the study, under the framework of prospective, single-center registry, the NSTEACS and MD patients were included. Depending on the strategy of revascularization, three groups were selected: staged PCI, coronary bypass (CBG) and PCI as the first with CBG as the second stage. As adverse cardiovascular events, the following were taken: death, myocardial infarction, stroke or transient cerebral ishemia, clinically significant bleeding by BARC, repeat nonscheduled revascularization of target vessel. Results. Analysis revealed the groups of factors increasing the probability of adverse cardiovascular events. Those are: (1) clinical and demographic — older age, diabetes, postinfarction cardiosclerosis, multifocal atherosclerosis, chronic renal failure; (2) coronary and surgical — left main stem lesion, severe atherosclerosis by SYNTAX Score, high surgical risk by EuroScore II, revascularization strategy; (3) predominance of low or moderate risk by GRACE comparing with high risk.Conclusion. The results have confirmed high predictional significance of clinical and demography and coronary factors for development of adverse cardiovascular diseases. A significant finding of the study was the fact that in a hospital with surgery and endovascular treatment available 24/7, the intermediate and low GRACE risk in NSTEACS and MD is a factor of adverse cardiovascular events development due to revascularization delays if the risk is not high.
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Affiliation(s)
- Yu. N. Neverova
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - R. S. Tarasov
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - O. A. Nagirnyak
- Research Institute for Complex Issues of Cardiovascular Diseases
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Li YH, Wang YC, Wang YC, Liu JC, Lee CH, Chen CC, Hsieh IC, Kuo FY, Huang WC, Sung SH, Chiu CZ, Hsu JC, Jen SL, Hwang JJ, Lin JL. 2018 Guidelines of the Taiwan Society of Cardiology, Taiwan Society of Emergency Medicine and Taiwan Society of Cardiovascular Interventions for the management of non ST-segment elevation acute coronary syndrome. J Formos Med Assoc 2018; 117:766-790. [PMID: 30017533 DOI: 10.1016/j.jfma.2018.06.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022] Open
Abstract
In Taiwan, the incidence of non-ST segment elevation acute coronary syndrome (NSTE-ACS) continues to increase in recent years. The purpose of this guideline is to help health care professionals in Taiwan to use adequate tests and treatments for management of NSTE-ACS. For rapid diagnosis, in addition to history and physical examination, 0/3 h rapid diagnosis protocol with high sensitivity cardiac troponin assay is recommended in this guideline. Dual antiplatelet and anticoagulation therapies are important parts in the initial treatment. Risk stratification should be performed to identify high risk patients for early coronary angiography. Through evaluation of the coronary anatomy and other clinical factors, the decision for coronary revascularization, either by percutaneous coronary intervention or coronary artery bypass grafting, should be decided by the heart team. The duration of dual antiplatelet therapy should be given for at least 12 months after discharge. Other secondary preventive medications are also recommended for long term use.
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Affiliation(s)
- Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chen Wang
- Division of Cardiology, Department of Internal Medicine, Asia University Hospital, Taichung, Taiwan; Department of Biotechnology, Asia University, Taichung, Taiwan; Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital, Taichung, Taiwan
| | - Yi-Chih Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Ju-Chi Liu
- Division of Cardiovascular Medicine, Department of Internal Medicine, Shuang Ho Hospital and Taipei Medical University, New Taipei City, Taiwan
| | - Cheng-Han Lee
- Department of Internal Medicine and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Chun-Chi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Feng-You Kuo
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Wei-Chun Huang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Shih-Hsien Sung
- Department of Medicine, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Chiung-Zuan Chiu
- Division of Cardiology, Shin-Kong Wu Ho Su Memorial Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Jung-Cheng Hsu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shu-Long Jen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Shuang Ho Hospital and Taipei Medical University, New Taipei City, Taiwan.
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Early versus delayed coronary artery bypass graft surgery for patients with non-ST elevation myocardial infarction. Coron Artery Dis 2018; 28:670-674. [PMID: 28723830 DOI: 10.1097/mca.0000000000000537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although coronary artery bypass graft surgery (CABG) has been proven to have mortality and morbidity benefits in patients with non-ST elevation myocardial infarction and multivessel disease, the appropriate timing of this procedure remains unclear. Therefore, we proposed a propensity score-matched analysis comparing the clinical outcomes between patients who underwent CABG within the first 48 h of admission (early CABG) and patients who underwent CABG after 48 h of admission (delayed CABG). PATIENTS AND METHODS Using the largest inpatient care database in the USA, the Nationwide Inpatient Sample, we identified patients with a primary diagnosis of acute myocardial infarction using the ICD 9-DM diagnosis codes. We then performed propensity score-matching analysis to control for 24 possible confounders. RESULTS We identified 31 969 patients in the Nationwide Inpatient Sample database with a primary diagnosis of acute myocardial infarction who underwent CABG. The mean age of the cohort was 64.5±11.5 years and 33.4% were female. After performing propensity-matching analysis, we obtained a subset of 1555 patients in each group, with a mean age of 64.7±10.1 years; the male to female ratio was ~4 : 1. The incidence of hemorrhage, shock, and cardiac, pulmonary, and renal complications was comparable between the two groups. The incidence of mortality was not statistically significant between the two groups (2% in the early CABG vs. 1.8% in the delayed CABG, P=0.695). The mortality risk factors were as follows: age more than 70 years [odds ratio (OR): 3.42, 95% confidence interval (CI): 1.85-6.34, P<0.001]; cardiogenic shock (OR: 3.22, 95% CI: 1.35-7.67, P=0.008); and mechanical circulatory support with balloon counterpulsation (OR: 2.93, 95% CI: 1.45-5.90, P=0.003). CONCLUSION CABG performed within 48 h of admission does not significantly increase the risk for in-hospital mortality compared with undergoing the procedure after 48 h of admission in propensity-matched patients.
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40
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Troponin I levels before bypass surgery after acute myocardial infarction; When to operate? JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.416286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Institution of localized high-frequency electrical stimulation targeting early myocardial infarction: Effects on left ventricle function and geometry. J Thorac Cardiovasc Surg 2018; 156:568-575. [PMID: 29609885 DOI: 10.1016/j.jtcvs.2018.01.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 12/20/2017] [Accepted: 01/13/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although strategies have focused on myocardial salvage/regeneration in the context of an acute coronary syndrome and a myocardial infarction (MI), interventions targeting the formed MI region and altering the course of the post-MI remodeling process have not been as well studied. This study tested the hypothesis that localized high-frequency stimulation instituted within a formed MI region using low-amplitude electrical pulses would favorably change the trajectory of changes in left ventricle geometry and function. METHODS At 7 days following MI induction, pigs were randomized for localized high-frequency stimulation (n = 5, 240 bpm, 0.8 V, and 0.05 ms pulses) or unstimulated (n = 6). Left ventricle geometry and function were measured at baseline (pre-MI) and at 7, 14, 21, and 28 days post-MI using echocardiography. MI size at 28 days post-MI was determined by histochemical staining and planimetry. RESULTS At 7 days post-MI and before randomization to localized high-frequency stimulation, left ventricular ejection fraction and end-diastolic volume was equivalent. However, when compared with 7-day post-MI values, left ventricle end-diastolic volume increased in a time-dependent manner in the MI unstimulated group, but the relative increase in left ventricle end-diastolic volume was reduced in the MI localized high-frequency stimulation group. For example, by 28 days post-MI, left ventricle end-diastolic volume increased by 32% in the MI unstimulated group but only by 12% in the MI localized high-frequency stimulation group (P < .05). Whereas left ventricular ejection fraction appeared unchanged between MI groups, estimates of pulmonary capillary wedge pressure, a marker of adverse left ventricle performance and progression to failure, increased by 62% in the MI unstimulated group and actually decreased by 17% in the MI localized high-frequency stimulation group when compared with 7-day post-MI values (P < .05). MI size was equivalent between the MI groups, indicative of no difference in the extent of absolute myocardial injury. CONCLUSIONS The unique findings from this study are 2-fold. First, targeting the MI region following the resolution of the acute event using a localized stimulation approach is feasible. Second, localized stimulation modified a key parameter of adverse post-MI remodeling (dilation) and progression to heart failure. These findings demonstrate that the MI region itself is a modifiable tissue and responsive to localized electrical stimulation.
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Abstract
BACKGROUND As a marker of myocardial injury, troponin level correlates with adverse outcomes after myocardial infarction (MI). We hypothesized that patients with a higher preoperative troponin level would have increased morbidity and mortality after coronary artery bypass grafting (CABG). METHODS Preoperative troponin measurements were available for 1,272 patients who underwent urgent or emergent isolated CABG at our institution from 2002 to 2016. Logistic regression assessed the risk-adjusted effect of peak troponin level on morbidity and mortality. Long-term survival analysis was performed with Kaplan-Meier and Cox proportional hazards models. RESULTS Preoperative troponin was positive in 835 patients (65.6%). The median peak troponin for this group was 3.2 ng/mL (interquartile range, 0.6 to 11.9 ng/mL), with a median time from peak troponin to the operation of 3 days (interquartile range, 1 to 4 days). Positive troponin was associated with more significant comorbid conditions and more extensive coronary artery disease. Operative mortality (3.7% versus 1.1%, p = 0.009), major morbidity (11.7% versus 3.9%, p < 0.001), and long-term mortality (median survival 12.5 years versus 13.6 years, p = 0.01) were increased in the positive troponin group. After risk adjustment, positive troponin was not independently associated with increased operative mortality (odds ratio, 2.61; p = 0.053). Adjusted and unadjusted analysis showed the peak preoperative troponin level did not independently predict death at any time point (all odds ratios, 1.0; p > 0.05). CONCLUSIONS A positive preoperative troponin correlates with worse outcomes after CABG, but risk adjustment eliminates much of the short-term predictive value of this biomarker. Peak troponin level does not influence outcomes after CABG and is a poor predictor of events when The Society of Thoracic Surgeons predictive models are used.
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Kim WJ, Jeong MH, Kang DG, Lee SU, Cho SK, Ahn Y, Kim YJ, Kim CJ, Cho MC. Clinical Outcomes of Elderly Patients with Non ST-Segment Elevation Myocardial Infarction Undergoing Coronary Artery Bypass Surgery. Chonnam Med J 2018; 54:41-47. [PMID: 29399565 PMCID: PMC5794478 DOI: 10.4068/cmj.2018.54.1.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/01/2018] [Accepted: 01/15/2018] [Indexed: 12/02/2022] Open
Abstract
The aim of this study is to investigate the clinical outcomes of the elderly patients with Non ST-segment elevation myocardial infarction (NSTEMI) undergoing coronary artery bypass surgery (CABG) compared to non-elderly patients. Patients with NSTEMI and undergoing CABG (n=451) who were registered in the Korea Acute Myocardial Infarction Registry between December 2003 and August 2012 were divided into two groups.; the non-elderly group (<75 years, n=327) and the elderly group (≥75 years, n=124). In-hospital mortality was higher in the elderly group (4.9% vs. 11.3%, p=0.015), but cardiac death, myocardial infarction, and major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, percutaneous revascularization, and redo-CABG after a one-year follow up were not different between the two groups. Predictors of in-hospital mortality in patients with NSTEMI undergoing CABG were left ventricular (LV) dysfunction (ejection fraction ≤40%) [hazard ratio (HR): 2.76, 95% confidence interval (CI): 1.16–6.57, p=0.022] and age (HR: 1.05, 95% CI: 1.01–1.10, p=0.047). So elderly NSTEMI patients should be considered for CABG if appropriate, but careful consideration for surgery is required, especially if the patients have severe LV systolic dysfunction.
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Affiliation(s)
- Woo Jin Kim
- Department of Cardiology, Kwangju Christian Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Dong Goo Kang
- Department of Cardiology, Kwangju Christian Hospital, Gwangju, Korea
| | - Seung Uk Lee
- Department of Cardiology, Kwangju Christian Hospital, Gwangju, Korea
| | - Sang Ki Cho
- Department of Cardiology, Kwangju Christian Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Young Jo Kim
- Department of Cardiology, Yeungnam University Hospital, Daegu, Korea
| | - Chong Jin Kim
- Department of Cardiology, Kyung Hee University Hospital, Seoul, Korea
| | - Myeong Chan Cho
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Korea
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Grieshaber P, Roth P, Oster L, Schneider TM, Görlach G, Nieman B, Böning A. Is delayed surgical revascularization in acute myocardial infarction useful or dangerous? New insights into an old problem. Interact Cardiovasc Thorac Surg 2018. [PMID: 28637179 DOI: 10.1093/icvts/ivx188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Haemodynamically stable patients admitted for coronary artery bypass grafting in acute myocardial infarction often undergo delayed surgery in order to avoid the risks of emergency surgery. However, initially stable patients undergoing delayed surgery may develop low cardiac output syndrome (LCOS) during the waiting period, which might be a major drawback of this strategy. We aim to define risk factors and clinical consequences of LCOS during the waiting period. METHODS A total of 530 consecutive patients with acute myocardial infarction (33% non-ST-segment elevation myocardial infarction and 67% ST-segment-elevation myocardial infarction) underwent isolated coronary artery bypass grafting between 2008 and 2013. Outcomes after either immediate (<48 h after onset of symptoms) or delayed (>48 h after onset of symptoms) therapy were compared. Predictors of preoperative development of LCOS were identified using multivariate regression analysis. RESULTS Of the 327 patients undergoing delayed therapy, 39 (12%) developed preoperative LCOS, resulting in increased mortality compared with patients who remained stable (21 vs 7.6%, P < 0.001). Immediate therapy resulted in similar mortality compared with delayed therapy (6.4 vs 7.6%; P = 0.68) and better 7-year survival (70 vs 55%; P < 0.001). Predictors of developing LCOS were reduced left ventricular function (odds ratio 4.4), renal impairment (odds ratio 3.0), acute pulmonary infection (odds ratio 3.4) and the extent of troponin elevation at admission (odds ratio 1.01 per increase by 1 µg/l). CONCLUSIONS In patients with acute myocardial infarction undergoing delayed coronary artery bypass grafting, preoperative LCOS is a relevant and dangerous condition that can be avoided by operating immediately or by carefully selecting patients to be delayed according to the risk parameters identified preoperatively.
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Affiliation(s)
- Philippe Grieshaber
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Peter Roth
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Lukas Oster
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Tobias M Schneider
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Gerold Görlach
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Bernd Nieman
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Andreas Böning
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
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Widmer RJ, Pollak PM, Bell MR, Gersh BJ, Anavekar NS. The Evolving Face of Myocardial Reperfusion in Acute Coronary Syndromes: A Primer for the Internist. Mayo Clin Proc 2018; 93:199-216. [PMID: 29329796 DOI: 10.1016/j.mayocp.2017.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/25/2017] [Accepted: 11/01/2017] [Indexed: 02/07/2023]
Abstract
Acute coronary syndromes (ACSs) account for a large proportion of disease burden in the United States and worldwide, and our understanding of ACS management continues to evolve. In this review we take a practical approach to evaluating and treating a patient with ACS, focusing on the optimal timing and methods of coronary reperfusion. Beginning with initial assessment and risk stratification, a provider managing the patient with ACS must be able to expeditiously decide on and implement the correct guideline-directed pathway to optimize outcomes. With an ever-growing body and weight of knowledge in this field, the clinician is tasked with several challenges. First, there are a variety of pathways of care to be considered; second, adjunctive medical therapies are expanding; and third, when coupled with the multiple combinations of adjunctive supportive therapies for revascularization, the variety of potential therapeutic options can be overwhelming and confusing. Herein, we carefully review all the relevant guidelines and the contributing literature, taking a 4-step approach: (1) review the importance of risk stratification before engaging in a particular strategy of care, (2) define the reperfusion strategies available, (3) review the specific agents (antiplatelet and anticoagulant) that support reperfusion strategies, and (4) apply the strategies of care in the context of the clinical presentation.
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Affiliation(s)
- R Jay Widmer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Peter M Pollak
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Bernard J Gersh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Desperak P, Hawranek M, Gąsior P, Desperak A, Lekston A, Gąsior M. Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST-segment elevation acute coronary syndromes. Cardiol J 2017; 26:157-168. [PMID: 28980282 DOI: 10.5603/cj.a2017.0110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/10/2017] [Accepted: 09/10/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is paucity of data concerning the optimal revascularization in patients with mul- tivessel coronary artery disease (CAD) presenting non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The aim was to evaluate long-term outcomes of patients with multivessel CAD presenting NSTE-ACS depending on the management after coronary angiography. METHODS 3,166 patients with NSTE-ACS hospitalized between 2006 and 2014 were screened. After ex- clusions, 1,342 patients were enrolled with multivessel CAD and were divided depending on their man- agement after coronary angiography; the medical-only therapy group (n = 91), the percutaneous coronary intervention (PCI) group (n = 1,122), the coronary artery bypass grafting (CABG) group (n = 129). Propensity scores matching was used to adjust for differences in patient baseline characteristics. RESULTS After propensity score analysis, 273 well-matched patients were chosen. Both before and after matching, patients treated with a medical-only therapy were burdened with the highest percentage of 24-month all-cause death and non-fatal MI in comparison to PCI and CABG groups, respectively. In the CABG group, ACS-driven revascularization rate was lowest. In the overall population, PCI (HR 0.33; 95% CI 0.20-0.53; p < 0.0001) and CABG (HR 0.54; 95% CI 0.31-0.93; p = 0.028) were independent factors associated with favorable 24-month prognosis. However, in a matched population only PCI was an independent predictor of long-term prognosis with a 63% decrease of 24-month mortal- ity (HR 0.37; 95% CI 0.19-0.69; p = 0.0020). CONCLUSIONS In patients with multivessel CAD presenting with NSTE-ACS, medical-only man- agement is related with adverse long-term prognosis in contrast to revascularization, which reduces 24-month mortality, especially among patients undergoing percutaneous intervention. Performance of PCI is an independent factor for improving long-term prognosis.
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Affiliation(s)
- Piotr Desperak
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland.
| | - Michał Hawranek
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Paweł Gąsior
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, Katowice, Poland
| | - Aneta Desperak
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Andrzej Lekston
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Mariusz Gąsior
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
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Lowenstern A, Newby LK. To Pretreat or Not to Pretreat (With Oral P2Y12 Antagonists)? That is the Question. J Am Heart Assoc 2017; 6:JAHA.117.007288. [PMID: 28939720 PMCID: PMC5634319 DOI: 10.1161/jaha.117.007288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Angela Lowenstern
- Division of Cardiology, Department of Medicine and the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine and the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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Pi Y, Roe MT, Holmes DN, Chiswell K, Garvey JL, Fonarow GC, de Lemos JA, Garratt KN, Xian Y. Utilization, Characteristics, and In-Hospital Outcomes of Coronary Artery Bypass Grafting in Patients With ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003490. [DOI: 10.1161/circoutcomes.116.003490] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 05/26/2017] [Indexed: 01/16/2023]
Abstract
Background—
There are limited data on the utilization and outcomes of coronary artery bypass grafting (CABG) among ST-segment–elevation myocardial infarction (STEMI) patients in contemporary practice.
Methods and Results—
Using data from National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines between 2007 and 2014, we analyzed trends in CABG utilization and hospital-level variation in CABG rates. Patients undergoing CABG during the index admission were categorized by the most common scenarios: (1) CABG only as the primary reperfusion strategy; (2) CABG after primary percutaneous coronary intervention; and (3) CABG after fibrinolytic therapy. A total of 15 145 patients (6.3% of the STEMI population) underwent CABG during the index hospitalization, with a decrease in utilization from 8.3% in 2007 to 5.4% in 2014 (trend
P
value <0.001). The hospital-level use of CABG in STEMI varied widely from 0.5% to 36.2% (median, 5.3%; interquartile range [IQR], 3.5%–7.8%;
P
value <0.001). Of all patients undergoing CABG, 45.8% underwent CABG only, 38.7% had CABG after percutaneous coronary intervention, and 8.2% CABG after fibrinolytic therapy. The median time intervals from cardiac catheterization/percutaneous coronary intervention to CABG were 23.3 hours (IQR, 3.0–70.3 hours) in CABG only, 49.7 hours (IQR, 3.2–70.3 hours) in CABG after percutaneous coronary intervention, and 56.6 hours (IQR, 22.7–96.0 hours) in CABG after fibrinolytic therapy. The Acute Coronary Treatment and Intervention Outcomes Network mortality risk scores differed modestly (median, 33; IQR, 28–40 versus median, 32; IQR, 27–38) between CABG and non-CABG patients. Patients undergoing CABG had similar in-hospital mortality rate (5.4% versus 5.1%) as those not treated with CABG.
Conclusions—
CABG is performed infrequently in STEMI patients during the index hospitalization, with rates declining in contemporary US practice over time. There was marked hospital-level variation in the use of CABG, and CABG was typically performed within 1 to 3 days after angiography. Observed mortality rates appear low, suggesting that CABG might be safely performed in select STEMI patients in a timely fashion.
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Affiliation(s)
- Yi Pi
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
| | - Matthew T. Roe
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
| | - DaJuanicia N. Holmes
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
| | - Karen Chiswell
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
| | - J. Lee Garvey
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
| | - Gregg C. Fonarow
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
| | - James A. de Lemos
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
| | - Kirk N. Garratt
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
| | - Ying Xian
- From the Duke Clinical Research Institute, Durham, NC (Y.P., M.T.R., D.N.H., K.C., Y.X.); China Oxford Centre for International Health Research, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China (Y.P.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.); Division of
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Klempfner R, Barac YD, Younis A, Kopel E, Younis A, Ronen G, Maor E, Arbel Y, Rott D, Goldenberg I, Aravot D. Early Referral to Coronary Artery Bypass Grafting Following Acute Coronary Syndrome, Trends and Outcomes from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000-2010. Heart Lung Circ 2017; 27:175-182. [PMID: 28325709 DOI: 10.1016/j.hlc.2017.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 01/11/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Limited information exists on whether changes in medical practices over the study decades have affected the outcomes of acute coronary syndrome (ACS) patients who undergo early coronary artery bypass surgery (CABG) during index hospitalisation. METHODS Data on trends for early CABG referral and associated outcomes were obtained among 11,485 ACS patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000-2010. RESULTS Among 11,485 patients, 566 (5%) were referred to early CABG. These patients displayed higher risk characteristics, including Killip class >II, anterior myocardial infarction, greater left ventricular dysfunction, and more frequent use of mechanical ventilation and intra-aortic balloon pump (all p<0.01). Nevertheless, mortality rates of patients referred to early CABG vs. treated with percutaneous coronary intervention (PCI) or medically, was similar (11.4% vs. 10.2%; log-rank p-value=0.40). There was a significant decline in the referral trend over the study decade (6.7% - 1.7%; p<0.001). One year survival was similar between patients referred to early CABG during the late (years: 2006-2010) vs. early (years: 2000-2005) period (85.7% vs. 90%; log-rank p-value=0.15), whereas, among patients who didn't undergo early CABG, and underwent percutaneous coronary intervention (PCI) or medical management only, enrolment during the late periods was associated with a significant survival benefit (91.5% vs. 88.1%; log-rank p-value<0.001). CONCLUSIONS Over the study decade there was a significant decline in referral for early CABG, without a difference in the one-year mortality between the early and non-early CABG group.
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Affiliation(s)
- Robert Klempfner
- The Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaron D Barac
- The Cardiothoracic Department, Rabin Medical Center, Tel Aviv, Israel
| | - Arwa Younis
- The Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Eran Kopel
- Epidemiology Department, Ministry of Health, Israel
| | - Anan Younis
- The Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Goldkorn Ronen
- The Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Maor
- The Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - David Rott
- The Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Goldenberg
- The Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Aravot
- The Cardiothoracic Department, Rabin Medical Center, Tel Aviv, Israel
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50
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Wang R, Cheng N, Xiao CS, Wu Y, Sai XY, Gong ZY, Wang Y, Gao CQ. Optimal Timing of Surgical Revascularization for Myocardial Infarction and Left Ventricular Dysfunction. Chin Med J (Engl) 2017; 130:392-397. [PMID: 28218210 PMCID: PMC5324373 DOI: 10.4103/0366-6999.199847] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: The optimal timing of surgical revascularization for patients presenting with ST-segment elevation myocardial infarction (STEMI) and impaired left ventricular function is not well established. This study aimed to examine the timing of surgical revascularization after STEMI in patients with ischemic heart disease and left ventricular dysfunction (LVD) by comparing early and late results. Methods: From January 2003 to December 2013, there were 2276 patients undergoing isolated coronary artery bypass grafting (CABG) in our institution. Two hundred and sixty-four (223 male, 41 females) patients with a history of STEMI and LVD were divided into early revascularization (ER, <3 weeks), mid-term revascularization (MR, 3 weeks to 3 months), and late revascularization (LR, >3 months) groups according to the time interval from STEMI to CABG. Mortality and complication rates were compared among the groups by Fisher's exact test. Cox regression analyses were performed to examine the effect of the time interval of surgery on long-term survival. Results: No significant differences in 30-day mortality, long-term survival, freedom from all-cause death, and rehospitalization for heart failure existed among the groups (P > 0.05). More patients in the ER group (12.90%) had low cardiac output syndrome than those in the MR (2.89%) and LR (3.05%) groups (P = 0.035). The mean follow-up times were 46.72 ± 30.65, 48.70 ± 32.74, and 43.75 ± 32.43 months, respectively (P = 0.716). Cox regression analyses showed a severe preoperative condition (odds ratio = 7.13, 95% confidence interval 2.05–24.74, P = 0.002) rather than the time interval of CABG (P > 0.05) after myocardial infarction was a risk factor of long-term survival. Conclusions: Surgical revascularization for patients with STEMI and LVD can be performed at different times after STEMI with comparable operative mortality and long-term survival. However, ER (<3 weeks) has a higher incidence of postoperative low cardiac output syndrome. A severe preoperative condition rather than the time interval of CABG after STEMI is a risk factor of long-term survival.
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Affiliation(s)
- Rong Wang
- Department of Cardiovascular Surgery, People's Liberation Army General Hospital, Beijing 100853, China
| | - Nan Cheng
- Department of Cardiovascular Surgery, People's Liberation Army General Hospital, Beijing 100853, China
| | - Cang-Song Xiao
- Department of Cardiovascular Surgery, People's Liberation Army General Hospital, Beijing 100853, China
| | - Yang Wu
- Department of Cardiovascular Surgery, People's Liberation Army General Hospital, Beijing 100853, China
| | - Xiao-Yong Sai
- Institute of Geriatrics, People's Liberation Army General Hospital, Beijing 100853, China
| | - Zhi-Yun Gong
- Department of Cardiovascular Surgery, People's Liberation Army General Hospital, Beijing 100853, China
| | - Yao Wang
- Department of Cardiovascular Surgery, People's Liberation Army General Hospital, Beijing 100853, China
| | - Chang-Qing Gao
- Department of Cardiovascular Surgery, People's Liberation Army General Hospital, Beijing 100853, China
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