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2018 AHA guidelines provide criteria to identify patients at very high risk (VHR) for adverse vascular events and recommend an low density lipoprotein-C (LDL-C) level ,1.8 mmol/L. Data regarding the 10-year risk for adverse vascular events in coronary artery bypass grafting (CABG) patients at VHR and the need for nonstatin therapies in the VHR cohort are limited. We queried a national cohort of CABG patients to answer these questions. The projected reduction of LDL-C from stepwise escalation of lipid-lowering therapy (LLT) was simulated; Monte Carlo methods were used to account for patient-level heterogeneity in treatment effects. Data on preoperative statin therapy and LDL-C levels were obtained. In the first scenario, all eligible patients not at target LDL-C received high-intensity statins, followed by ezetimibe and then alirocumab; alternatively, bempedoic acid was also used. The 10year risk for an adverse vascular event was estimated using a validated risk score. Potential risk reduction was estimated after simulating maximal LLT. Before CABG, 8948 of 27,443 patients (median LDL-C 85 mg/dL) were at VHR. In the whole cohort, 31% were receiving highintensity statins. With stepwise LLT escalation, the proportion of patients at target were 60%, 78%, 86%, and 97% after high-intensity statins, ezetimibe, bempedoic acid, and alirocumab, respectively. The projected 10-year risk to suffer a vascular event reduced by 4.6%. A large proportion of CABG patients who are at VHR for vascular events fail to meet 2018 AHA LDL-C targets. A stepwise approach, particularly with the use of bempedoic acid, can significantly reduce the need for more expensive proprotein convertase subtilisin kexin 9 inhibitors.

OBJECTIVES We analysed the Veteran Affairs data to evaluate the association of pre-operative glycated haemoglobin (HbA1c) and long-term outcome after isolated coronary artery bypass grafting (CABG). METHODS Veterans with diabetes mellitus and isolated CABG (2006–2018) were divided into 4 groups (I: HbA1c <6.5%, II: HbA1c 6.5–8, III 8–10% and IV: HbA1c >10%). The relationship of pre-operative HbA1c and long-term survival was evaluated with a multivariable Cox proportional hazards model and reported as hazard ratios (HR). The cumulative incidence of secondary end-points [myocardial infarction (MI) and repeat revascularization (percutaneous intervention)] for each group was modelled as competing events with cause-specific Cox proportional hazards models. RESULTS Overall, 16 190 patients (mean age 64.9 years, male 98%; insulin dependent 53%) with diabetes mellitus underwent isolated CABG. We observed 19.4%, 45.4%, 27% and 8.2% patients in groups I, II, III and IV, respectively. Patients with HbA1c >10% were the youngest (mean age 60.9 years) and had high rates of Insulin dependence (78%). In patients with HbA1c >10%, improvement in levels was observed in 76%. The median follow-up observed was 5.8 (3.2–8.8) years. Compared to the study mean HbA1c (7.3%), mortality rate increased with HbA1c levels >8%, and especially with pre-operative HbA1c levels >9%. Compared to patients with HbA1c <8%, HbA1c 8–10% and >10% were associated with increased MI (HR 1.24 and HR 1.39, respectively) and need for reintervention (HR 1.20 and HR 1.24, respectively). CONCLUSIONS In patients undergoing CABG, pre-operative HbA1c >8% is associated with the increased risk of mortality and adverse cardiac events.

Aims Despite the common occurrence of coronary artery disease (CAD) and heart failure (HF) with preserved ejection fraction (HFpEF), there is limited evidence to guide revascularization. Methods and Results We investigated the long‐term outcomes of coronary artery bypass grafting (CABG) in patients with HF and significant CAD across the spectrum of ejection fraction, using a large national cohort of patients from the Veteran Affairs (VA) Medical Centers in the US. Patients with HF were stratified into groups, HFpEF, HF with mid‐range ejection fraction (HFmrEF), and HF with reduced ejection fraction (HFrEF) and compared to patients with no preoperative HF. We analysed 10 396 patients. Despite an increased hazard in the first year following revascularization, the long‐term survival (median follow‐up 6.6 years; interquartile range 3.7–10.1) of HFpEF post‐CABG was similar to controls (hazard ratio 0.85, 95% confidence interval 0.68‐1.06), but survival progressively declined with HFmrEF and HFrEF. Similar trends were seen with recurrent HF hospitalization with lower risk with baseline HFpEF (43.9 ± 6.9/100 patient‐years) compared to HFmrEF (65.9 ± 3.8/100 patient‐years) and HFrEF (93.4 ± 4.8/100 patient‐years). Although HFpEF patients had lower mortality and HF hospitalization post‐CABG compared to patients with a lower ejection fraction, they experienced the highest rates of future myocardial infarction. Conclusion Although HFpEF patients with CAD have greater short‐term risk post‐CABG, their long‐term survival is comparable to controls. However, they are at increased risk for HF hospitalizations and myocardial infarction. These data support the safety of CABG in HFpEF patients and suggest continuum of mortality risk for ischaemic HF when stratified by baseline ejection fraction before revascularization.

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