Impact of previous coronary artery bypass grafting in patients presenting with an acute coronary syndrome: Current trends and clinical implications

Abstract

Background: Among patients presenting with an acute coronary syndrome, those with previous coronary artery bypass grafting are a particular subset. Aims: The purpose of this study was to investigate the prognostic impact of previous coronary artery bypass grafting in acute coronary syndrome patients and to identify the current trends in their clinical management. Methods: We performed a cohort analysis of patients prospectively enrolled in the Portuguese Registry of acute coronary syndrome between 2010–2019 with known previous coronary artery bypass grafting status. The co-primary endpoints were in-hospital and one-year mortality. Results: A total of 19,334 (962 coronary artery bypass grafting and 18,372 non-coronary artery bypass grafting) and 9402 (479 coronary artery bypass grafting and 8923 non-coronary artery bypass grafting) patients were included in the analyses of in-hospital and mid-term outcomes, respectively. Coronary artery bypass grafting patients were older and had a higher incidence of comorbidities. They were less likely to undergo invasive angiography (74.9 vs 84.6%, p<0.001), but were equally likely to receive dual antiplatelet therapy (91.0 vs 90.8%, p=0.823). In-hospital mortality was similar between groups (3.6 vs 3.4%, p=0.722). Unadjusted one-year mortality was higher in the coronary artery bypass grafting group (hazard ratio 1.48, 95% confidence interval 1.09–2.01, p=0.012), but similar in both groups after propensity-matching and multivariate analysis (hazard ratio 0.63, 95% confidence interval 0.37–1.09, p=0.098). Conclusions: Among patients with acute coronary syndrome, a previous history of coronary artery bypass grafting was associated with a high burden of comorbidities and a high-risk profile but was not an independent predictor of adverse events. Treatment decisions should be made on a case-by-case basis, and should not be based on previous coronary artery bypass grafting status alone.

Revascularisation and outcomes after acute coronary syndromes in patients with prior coronary artery bypass grafting–ANZACS-QI 67

“…[17][18][19][20] Although there is an evidence gap in the management of ACS in patients with prior CABG, PCI rates in this group has been consistently lower compared with patients without prior CABG. 2,4,14,[21][22] Patients with prior CABG in our study were significantly less likely to be referred for surgical revascularisation, likely due to older age, more complex coronary anatomy and higher risk profile. Previous studies have demonstrated higher mortality risk with repeat CABG when compared with medical management and revascularisation with PCI.…”

“…1 Several studies have also demonstrated similar findings. 2,[4][5][6]14 Prior CABG patients are more likely to present with UA and less likely to present with STEMI. A possible explanation is the formation of coronary arterial collaterals resulting in a smaller infarct size.…”

“…1 The culprit lesions may be in either a bypass graft or native vessels and the identification and treatment of culprit lesions may be more complex in the context of pre-existing multivessel disease. 1,2 Although current guidelines recommend an early invasive strategy in patients with acute coronary syndrome (ACS), these patients were excluded from the randomised clinical trials of invasive management. 3 They are an important sub-group to better understand-patients with prior CABG account for around one in 10 of those with ACS.…”

“…4,5 Patients with prior CABG have been reported to have higher morbidity and mortality up to one year. 1,2,[4][5][6] There is currently a lack of randomised clinical trial data in outcomes of invasive management of ACS in patients with prior CABG. Previous trials and guidelines of management of ACS often excluded prior CABG patients.…”

Long-Term Outcomes of Aortic Stenosis Patients with Different Flow/Gradient Patterns Undergoing Transcatheter Aortic Valve Implantation

“…Recent observational studies dedicated to LF-LG AS patients have outlined favorable early outcomes following TAVI [ 36 ] with lower 30-day mortality rates compared to those reported in prior TAVI studies evaluating LF-LG AS patients [ 31 , 37 ] as well as SAVR studies in LF-LG AS, despite including younger and lower risk patients [ 9 , 10 , 16 , 17 , 37 , 38 , 39 , 40 , 41 , 42 ]. However, despite the good early results post-TAVI in LF-LG AS patients and the constant optimization of the final hemodynamic result achieved with the latest THVs (transcatheter heart valves), the mid-term all-cause mortality remains high with approximately one-third of LF-LG patients dying after a median follow-up of 2-years [ 43 ]. Our study wished to expand on that knowledge and investigate whether this rise in all-cause mortality in LF-LG AS patients persists up to 5-years of follow-up and holds statistical significance over the other subgroups of AS patients.…”