Appropriate Timing of Coronary Artery Bypass Graft Surgery for Acute Myocardial Infarction Patients: A Meta-Analysis

Abstract

BackgroundCurrently, 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.MethodsWe 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.ResultsThe 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.ConclusionThe 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.

The association of timing of coronary artery bypass grafting for non-ST-elevation myocardial infarction and clinical outcomes in the contemporary United States

“…Finally, a meta-analysis by Lang et al . reiterates our findings of no significant difference in in-hospital mortality between early and later CABG groups [19]. The more contemporary results from the large present analysis and others suggesting similar mortality rates across time intervals are reassuring, especially considering that critically ill patients requiring urgent revascularization may be more likely to be included in the early CABG group.…”

“…Their results were similar to ours, but our study was unique in that we focused on NSTEMI, included a more homogeneous group by excluding high-risk cases, examined more recent years, and assessed perioperative outcomes in addition to in-hospital mortality. Finally, a metaanalysis by Lang et al reiterates our findings of no significant difference in in-hospital mortality between early and later CABG groups [19]. The more contemporary results from the large present analysis and others suggesting similar mortality rates across time intervals are reassuring, especially considering that critically ill patients requiring urgent revascularization may be more likely to be included in the early CABG group.…”

Optimal timing of surgical revascularization in patients with acute myocardial infarction

“…While some studies have shown an association between early CABG and surgical mortality following ACS treated with primary PCI, the optimal timing of CABG remains to be elucidated. Chen and Liu proposed a U-shaped distribution in mortality depending on the timing of surgery from AMI [Figure 1] [33] . This concept supports the idea that the lowest mortality can be achieved after the hyperacute phase of systemic inflammation and before the development of irreversible complications from myocardial injury.…”

“…The principal goal of optimizing the timing of CABG after primary PCI is to minimize surgical mortality and major cardiac and cerebrovascular events (MACCE). When emergent surgery is performed within 48 h of acute coronary syndrome (ACS), the mortality rate can reach 1,520%, compared to 4%-5% when surgery occurs after 48 h [31][32][33] . Table 3 provides a summary of the major studies that have addressed the timing of surgery in the context of ACS.…”

Timing of coronary artery bypass grafting in patients with myocardial infarction. Is the earlier the better?

“…A meta-analysis by Lang et al found that early CABG within 24 hours was associated with higher mortality and morbidity than late CABG after 24 hours in patients with ST-segment elevation myocardial infarction (STEMI), but not in patients with non-ST-segment elevation myocardial infarction (NSTEMI). 3 They suggested that CABG should be delayed until 24 hours later in STEMI patients, but not in NSTEMI patients. This implies that CABG can be performed with acceptable risks early in patients with NSTEMI.…”