Delay in coronary artery bypass grafting for STEMI patients improves hospital morbidity and mortality

Abstract

Objectives The optimal timing of coronary artery bypass grafting (CABG) in patients with ST elevated acute myocardial infarction (STEMI) is unclear. The purpose of the study is to evaluate and compare the outcomes in STEMI patients who underwent CABG within the various time intervals within the first 7 days of either emergent or urgent hospital admission. Methods Patients aged 30 years old and older diagnosed with STEMI who underwent CABG within first 7 days after non-elective hospital admission were selected from the National Inpatient Sample 2010–2014 using the appropriate ICD-9-CM diagnosis and procedure codes. These patients were divided into 3 cohorts based on timing of surgery: within 24 h (group A), 2nd-3rd day (group B), and 4th–7th day (group C). The rates of postoperative complications, mortality, and postoperative hospital length of stay (LOS) were compared using the Chi-square test, multivariable logistic regression analysis, and Wilcoxon rank sum test. Results A total of 5963 patients were identified: group A = 28.5%, group B = 36.1%, group C = 35.4%. Mean age overall was 63.1 ± 11.1 years; 76.9% were males and 72.9% were whites. Compared to groups B and C, patients in group A were more likely to develop cardiac complications (OR [odds ratio] =1.33, 95%CI [confidence interval] 1.12–1.59 and OR = 1.39, 95%CI 1.17–1.67, respectively) and respiratory complications (OR = 1.31, 95%CI 1.13–1.51 and OR = 1.53, 95%CI 1.32–1.78, respectively). They were also more likely to have renal complications (OR = 1.31, 95%CI 1.11–1.54) and bleeding (OR = 1.20, 95%CI 1.05–1.37) than patients in group B and had a similar tendency compared to group C. We did not find significant differences in the above complications between groups B and C. Postoperative stroke and sternal wound infection rates were similar between all three groups. In-hospital mortality was also higher in group A (8.2%) compared to group B (3.5%) and group C (2.9%, P < 0.0001 for both); differences between groups B and C were not significant. This was confirmed in the multivariable logistic regression analysis with controlling for age, gender, race, the Elixhauser Comorbidity Index, and complications (group A vs B: OR = 1.85, 95%CI 1.52–2.25; group A vs C: OR = 2.21; 95%CI 1.82–2.68). Patients in group A had a significantly longer postoperative LOS (median 7 days with IQR [interquartile range] 5–10 days) compared to those in group B (median 6 days, IQR 5–8 days) and group C (median 6 days, IQR 4–8 days; P < 0.0001 for both). Conclusions The results of this study show that despite the urgency and severity of STEMI, patients who undergo CABG within the first 24 h after non-elective hospital admission have increased hospital morbidity and mortality. These findings suggest that a delay in surgery beyond the first 24 h may be beneficial to patient outcomes. Furthermore, there is a significant cost effectiveness when the patients delay surgery because the hospital length of stay is reduced as well as the subsequent hospital costs.

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

“…The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart provided detailed descriptions of publication screening and reasons for exclusion are shown in Figure 1 . There were 6 prospective studies ( 3 – 5 , 8 , 10 , 11 ) and 13 retrospective studies ( 6 , 7 , 9 , 12 – 21 ). A total of 7 studies ( 7 – 9 , 11 , 16 , 18 , 21 ) were evaluated in the STEMI population, 4 studies ( 5 , 6 , 8 , 9 ) were evaluated in the NSTEMI population, and 10 studies ( 3 , 4 , 10 , 12 – 15 , 17 , 19 , 20 ) were evaluated in undefined STEMI/NSTEMI population.…”

“…There were 6 prospective studies ( 3 – 5 , 8 , 10 , 11 ) and 13 retrospective studies ( 6 , 7 , 9 , 12 – 21 ). A total of 7 studies ( 7 – 9 , 11 , 16 , 18 , 21 ) were evaluated in the STEMI population, 4 studies ( 5 , 6 , 8 , 9 ) were evaluated in the NSTEMI population, and 10 studies ( 3 , 4 , 10 , 12 – 15 , 17 , 19 , 20 ) were evaluated in undefined STEMI/NSTEMI population. Two studies ( 8 , 9 ) analyzed the data from patients of both STEMI and NSTEMI groups at the same time.…”

“…Studies have shown that early coronary artery revascularization may increase the risk of death. If there was no absolute indication for emergency surgical intervention, such as structural complications and persistent ischemia, delayed surgery should be considered ( 8 , 11 , 16 , 21 ). Additionally, other studies have identified early or emergency CABG as predictors of higher mortality ( 15 , 17 ).…”

Culprit vessel revascularization first with primary use of a dedicated transradial guiding catheter to reduce door to balloon time in primary percutaneous coronary intervention

“…It is important to consider that diagnostic angiography before PCI might provide valuable anatomical information that could change the reperfusion strategy, such as an emergency coronary artery bypass graft. However, coronary artery bypass graft was performed as reperfusion therapy in only 0.8% of patients ( 32 ), and patients requiring urgent or emergency coronary artery bypass graft within 24 h of STEMI have mortality rates of 8.2∼15.8% ( 33 , 34 ). In fact, for patients with STEMI and multivessel disease, immediate or staged complete revascularization with PCI significantly improves hard clinical outcomes ( 35 ).…”

Effectiveness of LODS, OASIS, and SAPS II to predict in-hospital mortality for intensive care patients with ST elevation myocardial infarction

“…PCI is the standard interventional treatment modality for patients with STEMI 12 , also was proved to be effective on one-year mortality in non-ST-segment elevation myocardial infarction (NSTEMI) patients 13 . Approximately 20–30% of patients are not eligible for PCI and require surgical intervention, that is, coronary artery bypass grafting (CABG) 14 , 15 . Therefore, we additionally investigated whether the included patients underwent PCI or CABG.…”