Does Timing of Coronary Artery Bypass Surgery Affect Early and Long-Term Outcomes in Patients With Non–ST-Segment–Elevation Myocardial Infarction?

Abstract

Background-Current guidelines do not provide recommendations for optimal timing of coronary artery bypass surgery (CABG) in patients with non-ST-segment-elevation myocardial infarction. Our study aimed to determine the impact of CABG timing on early and late outcomes in patients with non-ST-segment-elevation myocardial infarction. Methods and Results-A total of 758 patients underwent CABG within 21 days after non-ST-segment-elevation myocardial infarction between January 2008 and December 2012 at our institution. The patients were divided into 3 groups according to the time interval between symptom onset and CABG: group A, <24 hours (133 patients); group B, 24 to 72 hours (192 patients); and group C, >72 hours to 21 days (433 patients). Predictors of in-hospital and long-term mortality were identified by logistic and Cox regression analyses, respectively. Overall in-hospital mortality was 5.1% (39 patients): 6.0%, 4.7%, and 5.1% in groups A, B, and C (P=0.9), respectively. A total of 118 patients died during follow-up. The 5-year survival was 73.1±2%, with a nonsignificant trend toward better survival in groups A (78.2±4%) and C (75.4±3%) compared with group B (63.6±5%; log-rank P=0.06). Renal insufficiency and LMD were independent predictors of in-hospital (odds ratio, 3.1; P=0.001; and odds ratio, 3.1; P=0.002) and long-term mortality (hazard ratio, 1.7; P=0.004; and hazard ratio, 1.5; P=0.02), whereas administration of P2Y 12 inhibitors was protective (odds ratio, 0.3; P=0.01). Conclusions-Emergent CABG within 24 hours of non-ST-segment-elevation myocardial infarction is associated with in-hospital mortality and long-term outcomes similar to those of CABG performed after 3 days, despite a higher risk profile. CABG performed between 24 to 72 hours showed a nonsignificant trend toward poorer long-term outcomes. Dual antiplatelet therapy until surgery is beneficial, whereas renal insufficiency and left main disease increase the risk of early and late death. (Circulation. 2015;132:731-740.

Outcome of Stable Patients With Acute Myocardial Infarction and Coronary Artery Bypass Surgery Within 48 Hours: A Single‐Center, Retrospective Experience

“…It has become clear that the incidence of stroke per se is higher among patients with AMI, presumably due to the increased systemic inflammatory state . Although PCI‐focused AMI trials reported cerebrovascular event rates between ≈0.3% and 1%, stroke risks among AMI patients undergoing CABG range between 0.8% and 6% . We found a slightly although not statistically significant lower proportion of strokes in patients with STEMI compared with NSTEMI (2.0% versus 3.9%, P =0.134).…”

“…16 Although PCI-focused AMI trials reported cerebrovascular event rates between 0.3% and 1%, stroke risks among AMI patients undergoing CABG range between 0.8% and 6%. [3][4][5] We found a slightly although not statistically significant lower proportion of strokes in patients with STEMI compared with NSTEMI (2.0% versus 3.9%, P=0.134). The causes underlying perioperative strokes are multifactorial and thus difficult to modify.…”

“…2 Mohr and his group published one of the most recent studies on this subject. 3 They did not find any differences concerning the in-hospital mortality of 758 patients with non-ST-segment-elevation myocardial infarction (NSTEMI) when CABG was performed within 24 hours (6.0%), within 24 hours to 72 hours (4.7%), or within 21 days (5.1%). In a publication analyzing the CABG subgroup of the ACCOAST (Comparison of Prasugrel at the Time of PCI or as Pretreatment at the Time of Diagnosis in Patients with NSTEMI) study, 30-day mortality varied between 3.9% if patients had undergone CABG within 3 days and 1.9% if operative revascularization was performed later on.…”

“…As summarized by Caceres et al in 2013, >50% of publications reporting on CABG in AMI patients date back to the 1990s . Mohr and his group published one of the most recent studies on this subject . They did not find any differences concerning the in‐hospital mortality of 758 patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) when CABG was performed within 24 hours (6.0%), within 24 hours to 72 hours (4.7%), or within 21 days (5.1%).…”

Indications, algorithms, and outcomes for coronary artery bypass surgery in patients with acute coronary syndromes

“…Two observational studies from 2010 both reported equivalent in-hospital mortality and 30-day mortality rates irrespective of the timing of CABG from admission for NSTE-ACS [28,29]. A more recent study by Davierwala et al [30] analyzed 750 patients over a 5-year period and showed similar in-hospital mortality and 5-year mortality rates among NSTE-ACS patients who underwent CABG in less than 24, 24–72 h, versus more than 72 h after symptom onset. However, NSTE-ACS practice guidelines highlight certain conditions that should prompt urgent revascularization including cardiogenic shock, refractory ischemia despite optimal medical therapy, sustained ventricular arrhythmias, or dynamic ST-segment changes accompanying ischemic symptoms [4].…”