Revascularization after acute myocardial infarction

doi:10.1016/S0003-4975(95)00351-7

The Annals of Thoracic Surgery

Volume 60, Issue 1, July 1995, Pages 19-26

https://doi.org/10.1016/S0003-4975(95)00351-7 Get rights and content

Background.

The optimal timing for coronary artery bypass grafting (CABG) after acute myocardial infarction (MI) remains controversial.

Methods.

We examined our experience retrospectively in 3,942 patients who underwent CABG between 1986 and 1993, including 2,296 patients after acute MI.

Results.

The operative mortality associated with increasing time intervals between MI and CABG were 9.1%, 8.3%, 5.2%, 6.5%, and 2.9%, for less than 6 hours, 6 hours to 2 days, 2 to 14 days, 2 to 6 weeks, and more than 6 weeks, respectively. In comparison, the operative mortality was 2.5% for patients with no history of acute MI. The incidence of permanent stroke and perioperative MI were greater and the length of postoperative hospitalization was longer for patients undergoing CABG early after MI. For patients undergoing operation electively, however, the operative mortality associated with increasing time intervals between MI and CABG were less, at 0.0%, 3.6%, 2.1%, 6.4%, and 2.1% for less than 6 hours, 6 hours to 2 days, 2 to 14 days, 2 to 6 weeks, and more than 6 weeks, respectively. For patients undergoing CABG within 14 days of MI, the operative mortality was 5.3% for those receiving an intraaortic balloon pump preoperatively for postinfarction angina, but 11.8% for those who underwent urgent/emergent operation without intraaortic balloon pump support.

Conclusions.

Elective CABG can be accomplished with acceptable morbidity and mortality early after acute MI if an elective operation is possible. In addition, the intraaortic balloon pump should be used aggressively in patients with postinfarction angina to allow for elective rather than urgent/emergent operation.

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Cited by (81)

Timing of coronary artery bypass grafting after acute myocardial infarction may not influence mortality and readmissions
2021, Journal of Thoracic and Cardiovascular Surgery
Coronary artery bypass grafting is often delayed after acute myocardial infarction to avoid an increase in postoperative morbidity and mortality. We hypothesized that the timing of coronary artery bypass grafting after acute myocardial infarction may not be consistently associated with postoperative outcomes.
All patients who underwent isolated coronary artery bypass grafting at the University of Pittsburgh Medical Center from 2011 to 2017 after an acute myocardial infarction were reviewed. A comparative analysis for time from myocardial infarction presentation to coronary artery bypass grafting was performed with primary outcomes including all-cause mortality and readmission.
A total of 7048 patients underwent isolated coronary artery bypass grafting. Of these, 2058 patients had acute myocardial infarction with all relevant variables available for analysis. The study population was divided into 2 coronary artery bypass grafting timing cohorts, including less than 24 hours (n = 292) and 24 hours or more (n = 1766). Previous percutaneous coronary intervention, cardiogenic shock, and intra-aortic balloon pump were more prevalent in the less than 24 hours group. Operative mortality was significantly higher in the less than 24 hours cohort (7.19% vs 3.79%; P = .01). Diabetes mellitus, peripheral vascular disease, serum creatinine, age, chronic obstructive pulmonary disease, and immunosuppression were significant predictors (P < .05) of mortality. After risk adjustment with propensity scoring, there was no difference between time cohorts for operative mortality (4.15% vs 4.58%; P = .62). New-onset atrial fibrillation occurred more frequently in the 24 hours or more cohort. There was no difference between groups for the occurrence of major adverse cardiovascular and cerebrovascular event readmissions.
After adjusting for baseline patient characteristics, there was no statistically significant difference between timing cohorts for mortality or major adverse cardiovascular and cerebrovascular event readmissions.
Early Referral to Coronary Artery Bypass Grafting Following Acute Coronary Syndrome, Trends and Outcomes from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000–2010
2018, Heart Lung and Circulation
Limited information exists on whether changes in medical practices over the study decades have affected the outcomes of acute coronary syndrome (ACS) patients who undergo early coronary artery bypass surgery (CABG) during index hospitalisation.
Data on trends for early CABG referral and associated outcomes were obtained among 11,485 ACS patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000–2010.
Among 11,485 patients, 566 (5%) were referred to early CABG. These patients displayed higher risk characteristics, including Killip class >II, anterior myocardial infarction, greater left ventricular dysfunction, and more frequent use of mechanical ventilation and intra-aortic balloon pump (all p < 0.01). Nevertheless, mortality rates of patients referred to early CABG vs. treated with percutaneous coronary intervention (PCI) or medically, was similar (11.4% vs. 10.2%; log-rank p-value = 0.40).
There was a significant decline in the referral trend over the study decade (6.7% – 1.7%; p < 0.001). One year survival was similar between patients referred to early CABG during the late (years: 2006–2010) vs. early (years: 2000–2005) period (85.7% vs. 90%; log-rank p-value = 0.15), whereas, among patients who didn’t undergo early CABG, and underwent percutaneous coronary intervention (PCI) or medical management only, enrolment during the late periods was associated with a significant survival benefit (91.5% vs. 88.1%; log-rank p-value<0.001).
Over the study decade there was a significant decline in referral for early CABG, without a difference in the one-year mortality between the early and non-early CABG group.
Timing of coronary artery bypass graft surgery for acute myocardial infarction patients: A meta-analysis
2014, International Journal of Cardiology
Optimal timing of coronary artery bypass grafting in acute myocardial infarction
2013, Annals of Thoracic Surgery
Citation Excerpt :
The Society of Thoracic Surgeons (STS) database reported a mortality rate of 7.9% for CABG within 24 hours after a MI; however, the mortality rate dropped to 2% after excluding salvage operations, renal failure, and age older than 70 years [44]. The higher risk profile of patients undergoing urgent and emergency revascularization after MI has been validated in many studies [14, 19, 20, 22, 25, 26]. We believe that the increased mortality rate in early CABG is related to the acuity of presentation more than to the time elapsed before the operation.
The timing of surgical coronary artery revascularization after an acute myocardial infarction is not well defined. The inherent difficulties of mobilizing a surgical team at odd hours has led to the adoption of a percutaneous coronary intervention strategy when possible or a clot-busting drug regimen when percutaneous coronary intervention is not available. Despite the difficulties and risks of surgical revascularization, there are situations where it may be indicated. We conducted a review of the literature to better understand the timing, scope, and risks of surgical coronary revascularization after an acute myocardial infarction.
2011 ACCF/AHA guideline for coronary artery bypass graft surgery
2011, Journal of the American College of Cardiology
A clinical score to predict the need for intraaortic balloon pump in patients undergoing coronary artery bypass grafting
2010, Annals of Thoracic Surgery
There is no accepted consensus on the definition of high-risk patients who may benefit from the use of intraaortic balloon pump (IABP) in coronary artery bypass grafting (CABG). The aim of this study was to develop a risk model to identify high-risk patients and predict the need for IABP insertion during CABG.
From April 1996 to December 2006, 8,872 consecutive patients underwent isolated CABG; of these 182 patients (2.1%) received intraoperative or postoperative IABP. The scoring risk model was developed in 4,575 patients (derivation dataset) and validated on the remaining patients (validation dataset). Predictive accuracy was evaluated by the area under the receiver operating characteristic curve.
Mortality was 1% in the entire cohort and 18.7% (22 patients) in the group which received IABP. Multivariable analysis showed that age greater than 70 years, moderate and poor left ventricular dysfunction, previous cardiac surgery, emergency operation, left main disease, Canadian Cardiovascular Society 3-4 class, and recent myocardial infarction were independent risk factors for the need of IABP insertion. Three risk groups were identified. The observed probability of receiving IABP and mortality in the validation dataset was 36.4% and 10% in the high-risk group (score >14), 10.9% and 2.8% in the medium-risk group (score 7 to 13), and 1.7% and 0.7% in the low-risk group (score 0 to 6).
This simple clinical risk model based on preoperative clinical data can be used to identify high-risk patients who may benefit from elective insertion of IABP during CABG.

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Original articleRevascularization after acute myocardial infarction

Background.

Methods.

Results.

Conclusions.

Am J Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Intravenous tissue plasminogen activator and size of infarct, left ventricular function, and survival in acute myocardial infarction

Br Med J

Effect of intravenous APSAC on mortality after acute myocardial infarction: Preliminary report of a placebo-controlled clinical trial

Lancet

Original article
Revascularization after acute myocardial infarction