Optimal timing of revascularization: transmural versus nontransmural acute myocardial infarction

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

BACKGROUND

In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA.

METHODS

We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24 h, 24-72 h, 72-120 h, and >120 h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost.

RESULTS

A total of 147 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120 h and at >120 h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24 h from admission. In addition to these differences, CABG at >120 h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24 h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24 h.

CONCLUSION

CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.

Outcomes of Patients Presenting with Non-ST Elevation Myocardial Infarction Undergoing Surgical Revascularization

Non-ST-segment elevation myocardial infarction (NSTEMI) is a leading cause of emergency hospitalisation across Europe. This study evaluates the in-hospital and mid-term outcomes of patients undergoing coronary artery bypass grafting (CABG) following NSTEMI. A retrospective analysis of all cases undergoing isolated CABG following NSTEMI from September/2017 to September/2022 at our Centre. Patients were stratified according to in-hospital survival. Patient characteristics, operative details, and procedural complications were compared between those who survived and those who did not. Predictors of in-hospital and mid-term mortality were evaluated using logistic and Cox regression modelling. Kaplan Meier analysis was used to generate a survival curve for all alive patients at the time of discharge. Among 1011 patients (median age 64 [56 - 72] years, 852 [84.3%] male), 735 (72.7%) underwent urgent, 239 (23.6%) elective, and 37 (3.7%) emergency CABG. The in-hospital mortality was 1.5% (15/1011 patients). Those who died were more likely to be NYHA class III/IV, have LVEF <21%, severe renal impairment, peripheral vascular disease (PVD), or poor mobility. Emergency procedures, pre-operative ventilation, inotropic support, and intra-aortic balloon pump (IABP) use were also more prevalent among those who died. Logistic regression modelling revealed new postoperative stroke (OR:22.0; 95% CI:3.6-135.5; p=0.001), pre-operative IABP use (11.4; 2.4-53.7; p=0.002), new haemodialysis (9.6; 2.7-34.7; p<0.001), PVD (5.6; 1.6-20.0; p=0.008), and poor mobility (OR: 4.8; 95% CI: 1.3-18.2; p=0.022) as independent predictors of in-hospital mortality. In conclusion, new postoperative stroke, pre-operative IABP use, new haemodialysis, PVD and poor mobility are independent predictors of mortality in NSTEMI patients undergoing isolated CABG.

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

Background

Currently, 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.

Methods

We 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.

Results

The 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.

Conclusion

The 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.

Meta-Analysis of Nonrandomized Studies to Assess the Optimal Timing of Coronary Artery Bypass Grafting After Acute Myocardial Infarction

The optimal timing of coronary artery bypass grafting (CABG) in patients after an acute myocardial infarction (MI) is unknown. We performed a systematic review and meta-analysis of studies comparing mortality rates in patients who underwent CABG at different time intervals after acute MI. Bias assessments were completed for each study, and summary of proportions of all-cause mortality were calculated based on CABG at various time intervals after MI. A total of 22 retrospective studies, which included a total of 137,373 patients were identified. The average proportion of patients who died when CABG was performed within 6 hours of MI was 12.7%, within 6 to 24 hours of MI was 10.9%, within 1 day of MI was 9.8%, any time after 1 day of MI was 3.0%, within 7 days of MI was 5.9%, and any time after 7 days of MI was 2.7%. Interstudy heterogeneity, assessed using I² values, showed significant heterogeneity in death rates within subgroups. Only 1 study accounted for immortal time bias, and there was a serious risk of selection bias in all other studies. Confounding was found to be a serious risk for bias in 55% of studies because of a lack of accounting for type of MI, MI severity, or other verified cardiac risk factors. The current publications comparing timing of CABG after MI is at serious risk of bias because of patient selection and confounding, with heterogeneity in both study populations and intervention time intervals.

Timing of coronary artery bypass grafting after acute myocardial infarction: does it influence outcomes?

Introduction

The optimal timing of coronary artery bypass grafting (CABG) operations in patients with recent acute myocardial infarction (AMI) remains unclear.

Aim

To assess the influence of timing on post-operative outcomes in patients undergoing CABG following AMI.

Material and methods

In this retrospective analysis 12,224 consecutive patients undergoing CABG were included. 2477 (20.5%) patients had a history of AMI. Based on timing, patients were divided into 3 groups: those operated within 7 days of AMI; those operated after 7 days but within 1 month; and a third group operated after 1 month but within 3 months. The 3 groups were compared in terms of baseline, intra-operative, and post-operative morbidity and mortality. Multivariate analysis was carried out to assess the independent influence of timing of CABG on outcomes.

Results

There was no difference in terms of previous neurological events (p = 0.554), presence of carotid artery disease (p = 0.555), prevalence of hypertension (p = 0.119), diabetes (p = 0.144), hypothyroidism (p = 0.53), chronic obstructive pulmonary disease (p = 0.079), peripheral vascular disease (p = 0.771), and impaired left ventricular function (p = 0.072). On univariate analysis, mortality risk was highest between 1 week and 1 month (p = 0.003). Multivariate analysis showed that the closer the MI and CABG duration, the higher the mortality (co-efficient -0.517; p = 0.019; odds ratio = 0.596; 95% CI: 0.388-0.917).

Conclusions

The duration between MI and CABG has a direct influence on outcomes after CABG. While it is clear that the longer the duration between MI and CABG, the lower the mortality risk, it is however difficult to decide on an exact cut-off time frame.

Outcomes of non-elective coronary artery bypass grafting performed on weekends

OBJECTIVES

A weekend effect with increased mortality has previously been reported in surgical patients and those with acute myocardial infarction (MI). We hypothesized that a similar phenomenon may exist in coronary artery bypass grafting (CABG).

METHODS

Patients undergoing non-elective isolated CABG (2011-2017) were included from a multicentre regional Society of Thoracic Surgeons database. Patients were stratified by weekend versus weekday operations and further analysed by specific day of the week.

RESULTS

A total of 14 374 patients underwent urgent or emergency isolated CABG with 410 (2.9%) operated on over the weekend. Weekend operations were more often emergency (36.1% vs 5.0%, P < 0.001) and more likely to be in the setting of MI (70.0% vs 51.2%, P < 0.001). Cardiopulmonary bypass times were similar [91 min (71-114) vs 94 min (74-117), P = 0.0749] and the frequency of complete revascularization equivalent (83.4% vs 85.3%, P = 0.284) between weekend and weekday operations. In risk-adjusted analyses, there was no increased odds for mortality in patients operated on over the weekend [odds ratio (OR) 1.07, P = 0.811]; however, there was an increased odds of major morbidity (OR 1.37, P = 0.034). Furthermore, compared with Monday, morbidity increased as the operative day approached the weekend (Tuesday 0.98, P = 0.828; Wednesday 1.07, P = 0.469; Thursday 1.12, P = 0.229; Friday 1.19, P = 0.041; weekend 1.47, P = 0.014).

CONCLUSIONS

While patients requiring surgery on the weekend are higher risk, there is no independent effect of weekend surgery on mortality. However, these patients are at increased risk for major morbidity, the causes of which require further investigation.

Timing of Coronary Artery Bypass Grafting in Acute Coronary Syndrome: A National Analysis

BACKGROUND

Timing of surgical revascularization for acute coronary syndrome (ACS) remains debated. We assessed the impact of timing to CABG on mortality and resource utilization in a national cohort.

METHODS

Adults admitted for ACS in the 2009-2018 National Inpatient Sample were grouped by time from coronary angiography to CABG (Δt): 0, 1-3, 4-7, and >7 days. Generalized linear models were fit to evaluate associations between Δt and in-hospital mortality and hospitalization costs. Timing and mortality of CABG for ACS was compared between high-performing hospitals (below the median risk adjusted mortality for all CABG and valve operations) and others.

RESULTS

Of 444,065 patients, time to CABG was Δt=0 in 12.3%, Δt=1-3 in 57.3%, Δt=4-7 in 26.3%, and Δt>7 in 4.2%. Risk-adjusted mortality was greatest at Δt=0 (4.5%, 95% confidence interval, CI, 4.1-4.9) and Δt>7 (4.0%, 95% CI 3.4-4.7), but similar for operations performed at Δt=1-3 (1.8%, 95% CI 1.7-1.9) and Δt=4-7 (2.1%, 95% CI 1.9-2.3). Compared to Δt=1-3, hospitalization costs were greater by $6,400 (95% CI 5,900-6,900) for Δt=4-7 and $21,200 (95% CI 19,800-22,600) for Δt>7. High-performing hospitals had similar time to CABG as others (2 vs 2 days, p=0.17), but lower mortality (0.9% vs 3.3%, p<0.001).

CONCLUSIONS

Revascularization on day 1-3 and 4-7 led to comparable in-hospital mortality, with greater rates on day 0 and after day 7. Costs were greater for revascularization at day 4-7 compared to day 1-3. These findings support the reduction of time to revascularization to 1-3 days when deemed clinically appropriate and feasible.

Electrical Substrate Ablation for Refractory Ventricular Fibrillation: Results of the AVATAR Study

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Early surgical myocardial revascularization as an effective method of treating patients with acute coronary syndrome

BACKGROUND

One of the main methods of treating patients with acute coronary syndrome (ACS) is percutaneous coronary intervention (PCI), however in patients with multivascular, abnormal, or technically complicated coronary lesions, early surgical myocardial revascularization is more promising. Despite modern development of surgical and interventional techniques, the application of one strategy for all patients with acute coronary syndrome is problematic and should be based on the heart team's decision and patient data.

AIM

The study was aimed at assessing the results of early surgical myocardial revascularization in patients with acute coronary syndrome.

PATIENTS AND METHODS

Retrospectively with continuous sampling the study included 342 patients who underwent surgical treatment of acute coronary syndrome at the Federal Centre of High Medical Technologies from January 1st, 2014 to December 31st, 2018. Myocardial revascularization using two internal thoracic arteries was performed in 220 (64.3%) cases. The mean age of the patients was 64.2±10.8 years. Prevailing in the study were men - 69.3%. The average number of affected vessels amounted to 3.1±0.9. Fifty-six (16.4%) patients had cardiogenic shock at the time of operation, with 9 (2.6%) patients diagnosed as having severe mitral insufficiency and 5 (1.5%) with interventricular septal defect. All patients were on antiplatelet therapy.

RESULTS

In-hospital mortality was 5.2% (18 patients). The mean time of operation amounted to 205.3±58.9 min, with that of artificial circulation to 57.9±13.2 min. Such complication as postoperative haemorrhage was observed in 20 cases (5.8%). The average volume of drainage losses amounted to 507.3±66.7 ml. The average length of stay in the ICU was 3.8±1.4 days, with that of hospital stay being 16.6±2.1 days. Twenty-seven (7.9%) patients after removal of drainages were diagnosed as having exudative pericarditis which resolved on the background of medicamentous therapy.

CONCLUSION

Early surgical myocardial revascularization in patients with acute coronary syndrome may be performed safely and effectively, and should be considered individually in each patient by the heart team.

Surgical revascularization for acute coronary syndromes: a report from the North Rhine-Westphalia surgical myocardial infarction registry

OBJECTIVES

The aim of this was to analyse current outcomes in patients referred to coronary artery bypass grafting (CABG) for acute coronary syndromes (ACSs), including ST-elevation or non-ST-elevation ACS (non-ST-segment elevation myocardial infarction) or unstable angina.

METHODS

Patients (n = 2432) undergoing CABG for ACS between January 2010 and December 2017 were prospectively entered into a surgical myocardial infarction registry in North Rhine-Westphalia, Germany. Key end points were in-hospital all-cause mortality (IHM) and major adverse cardio-cerebral events (MACCE). Predictors for IHM and MACCE were analysed by multivariable logistic regression.

RESULTS

Patients (78% males) were referred for CABG for unstable angina (25%), non-ST-segment elevation myocardial infarction (50%), and ST-segment elevation myocardial infarction (25%). The mean patient age was 68 ± 11 years, logistic EuroSCORE was 19 ± 18% and three-vessel and left main stem diseases were diagnosed in 81% and 45% of patients, respectively. On-pump CABG with cardiac arrest or beating heart was performed in 92% and 2%, respectively, with only 6% off-pump surgery and 6% multiple arterial revascularization (3.1 ± 1.0 grafts, 93% left internal thoracic artery). Emergency CABG was performed in 23% of patients (42% in ST-segment elevation myocardial infarction; P < 0.001). The total IHM and MACCE rates were 8.1% and 17.5% and were highest in ST-segment elevation myocardial infarction patients with 12.6% and 28.5%, respectively (P < 0.001). Key predictors for IHM and MACCE were female gender, elevated troponin, left ventricular ejection fraction, inotropic support, logistic EuroSCORE, cardiopulmonary bypass and aortic clamp time and the need for emergency CABG.

CONCLUSIONS

Surgical myocardial revascularization in patients with ACS is still linked to substantial in-hospital mortality. Emergency CABG for patients with ACS was associated with poorer outcomes.

Outcomes After ST-Segment Versus Non-ST-Segment Elevation Myocardial Infarction Revascularized by Coronary Artery Bypass Grafting

The objectives of this study were to investigate the outcome differences between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients treated with coronary artery bypass grafting surgery (CABG). We conducted a multicenter, retrospective cohort follow-up study of consecutive patients with STEMI (surgery ≤48 hours of admission; n = 348) or NSTEMI (n = 1,160) revascularized with first-time isolated CABG in Finland using nationwide registries (median age 68 years, 24% women). The short- and long-term (10-year) outcomes were studied with inverse propensity probability weight adjustment for baseline features. The median follow-up was 5.2 years. In-hospital mortality (11.4% vs 5.3%; adj. odds ratio [OR] 2.27; confidence interval [CI] 1.41 to 3.66; p = 0.001) and re-sternotomy rates (6.9% vs 3.5%; adj. OR 2.07; CI 1.22 to 3.51; p = 0.007) were higher in STEMI patients. Long-term all-cause mortality did not differ between STEMI and NSTEMI patients among all operated patients (30.2% vs 28.3%; adj. HR 1.30; CI 0.97 to 1.75; p = 0.080) or hospital survivors (21.6 vs 24.3%; HR 0.93; CI 0.64 to 1.36; p = 0.713). Occurrence of major adverse cardiovascular event in hospital survivors within 10 years was 34.7% in STEMI versus 29.6% in NSTEMI (adj. HR 1.24; CI 0.88 to 1.76; p = 0.220). Occurrences of cardiovascular death (14.6% vs 14.4%; p = 0.773), myocardial infarction (MI; 15.2% vs 10.3%; p = 0.203), and stroke (10.8% vs 14.8%; p = 0.242) were also comparable. In conclusion, patients with STEMI have poorer short-term outcome compared to NSTEMI patients after revascularization by CABG, but the long-term outcomes are comparable regardless of MI type. Thus, both short- and long-term risks should be considered when evaluating patient´s for CABG eligibility by MI type.

Trends in Utilization and Safety of In-Hospital Coronary Artery Bypass Grafting During a Non-ST-Segment Elevation Myocardial Infarction

Up to 10% of non-ST-segment elevation myocardial infarction (NSTEMI) patients require coronary artery bypass graft (CABG) surgery during their hospitalization. Contemporary, real-world, data regarding CABG utilization and safety in NSTEMI patients are lacking. Our objectives were to investigate the contemporary trends in utilization and outcomes of CABG in patients admitted for NSTEMI. Using the 2003 to 2015 National Inpatient Sample data, we identified hospitalizations for NSTEMI, during which a CABG was performed. Patients' sociodemographic and clinical characteristics, incidence of surgical complications, length of stay, and mortality were analyzed. Multivariate analyses were performed to identify predictors of in-hospital complications and mortality. An estimated total of 440,371 CABG surgeries, during a hospitalization for NSTEMI, were analyzed. The utilization of CABG was steady over the years. The data show increasing prevalence of individual co-morbidities as well as cases with Deyo Co-morbidity Index ≥2 (p <0.001). High, 26.4%, complication rate was driven mainly by cardiac and pulmonary complications. The mortality rate declined from 3.6% in 2003 to an average of 2.4% during 2010 to 2015. Older age, female gender, heart failure, and delayed CABG timing were independent predictors of adverse outcomes. In conclusion, utilization of in-hospital CABG as the primary revascularization strategy in patients with NSTEMI remained steady over the years. These data reveal the raising prevalence of co-morbidities during the study. High complication rate was recorded; however, the mortality declined over the years to about 2.4%. Delaying CABG was associated with small but statistically significant worsening in outcomes.

Early Clinical Outcomes of Surgical Myocardial Revascularization for Acute Coronary Syndromes Complicated by Cardiogenic Shock: A Report From the North-Rhine-Westphalia Surgical Myocardial Infarction Registry

Background

Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock (CS) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) and ST‐segment–elevation myocardial infarction (STEMI).

Methods and Results

Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in‐hospital mortality (IHM) and major adverse cardiocerebral events (MACCEs). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI (P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On‐pump surgery with cardioplegia was the preferred surgical technique in CS. IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI (IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score.

Conclusions

Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.

Impact of troponin I level on coronary artery bypass grafting outcomes

PURPOSE

The effect of preoperative cardiac troponin level on outcomes after coronary artery bypass grafting (CABG) is unclear. We investigated the impact of preoperative cardiac troponin I (cTnI) level as well as the time interval between maximum cTnI and surgery on CABG outcomes.

METHODS

All patients who underwent isolated CABG at our institution between 2009 and 2016 and had preoperative cTnI level available were identified using our Society of Thoracic Surgeons registry. Receiver operating characteristic (ROC) analysis was performed to identify a cTnI threshold level. Subjects were divided into groups based on this value and outcomes compared.

RESULTS

A total of 608 patients were included. ROC analysis identified 5.74 µg/dL as the threshold value associated with worse postoperative outcomes. Patients with peak cTnI >5.74 µg/dL underwent CABG approximately 1 day later, had twice the risk of adverse postoperative events, and had 2.8 day longer postoperative length of stay than those with peak cTnI ≤5.74 µg/dL. cTnI level was not associated with mortality or 30-day readmission. Time interval between peak cTnI and surgery did not affect outcomes.

CONCLUSION

Elevated preoperative cTnI level beyond a certain threshold value is associated with adverse postoperative outcomes but is not a marker for increased mortality. Time from peak cTnI does not affect postoperative outcomes or mortality and may not need to be considered when deciding timing of CABG.

Early surgical myocardial revascularization in non-ST-segment elevation acute coronary syndrome

Background

In non-ST-elevation myocardial infarction (NSTEMI) there is no consensus regarding optimal time point for coronary artery bypass grafting (CABG). Recent findings suggest that long-term outcomes are improved in early-revascularized NSTEMI patients. However, it has been stated that early surgery is associated to increased operative risk. In this study, we wanted to elucidate if early CABG in non-ST-elevation acute coronary syndrome can be performed safely.

Methods

We performed a monocentric-prospective observational study within a 2-year interval. A total of 217 consecutive patients (41 female, age 68.9±10.2, ES II 6.62±8.56) developed NSTEMI and underwent CABG. Patients were divided into two groups according to the time point of coronary artery bypass after symptom onset (group A: <72 h; group B: >72 h). Endpoints included 6-month mortality and incidence of MACE (death, stroke or re-infarction).

Results

There were no differences regarding mortality between both groups (30 days: group A 2.4% vs. group B 3.7%; P=0.592; 6 months: 8.4% vs. 6.0%; P=0.487). Incidence of MACE in the 6-month follow-up was also similar in both groups (group A: 9.6% vs. 9.7%, P=0.982). Regression analysis revealed as independent risk factors for mortality in the entire cohort ES II OR 1.045 (95% CI: 1.004-1.088). ES II remained an independent prognostic factor in group A OR 1.043 (95% CI: 1.003-1.086) and group B OR 1.032 (95% CI: 1.001-1.063).

Conclusions

Early revascularized patients showed a higher level of illness. However, results of early CABG were comparable to those following delayed revascularization. Moreover, EuroSCORE II was determined as independent risk factors for mortality.

Early versus delayed coronary artery bypass graft surgery for patients with non-ST elevation myocardial infarction

BACKGROUND

Although coronary artery bypass graft surgery (CABG) has been proven to have mortality and morbidity benefits in patients with non-ST elevation myocardial infarction and multivessel disease, the appropriate timing of this procedure remains unclear. Therefore, we proposed a propensity score-matched analysis comparing the clinical outcomes between patients who underwent CABG within the first 48 h of admission (early CABG) and patients who underwent CABG after 48 h of admission (delayed CABG).

PATIENTS AND METHODS

Using the largest inpatient care database in the USA, the Nationwide Inpatient Sample, we identified patients with a primary diagnosis of acute myocardial infarction using the ICD 9-DM diagnosis codes. We then performed propensity score-matching analysis to control for 24 possible confounders.

RESULTS

We identified 31 969 patients in the Nationwide Inpatient Sample database with a primary diagnosis of acute myocardial infarction who underwent CABG. The mean age of the cohort was 64.5±11.5 years and 33.4% were female. After performing propensity-matching analysis, we obtained a subset of 1555 patients in each group, with a mean age of 64.7±10.1 years; the male to female ratio was ~4 : 1. The incidence of hemorrhage, shock, and cardiac, pulmonary, and renal complications was comparable between the two groups. The incidence of mortality was not statistically significant between the two groups (2% in the early CABG vs. 1.8% in the delayed CABG, P=0.695). The mortality risk factors were as follows: age more than 70 years [odds ratio (OR): 3.42, 95% confidence interval (CI): 1.85-6.34, P<0.001]; cardiogenic shock (OR: 3.22, 95% CI: 1.35-7.67, P=0.008); and mechanical circulatory support with balloon counterpulsation (OR: 2.93, 95% CI: 1.45-5.90, P=0.003).

CONCLUSION

CABG performed within 48 h of admission does not significantly increase the risk for in-hospital mortality compared with undergoing the procedure after 48 h of admission in propensity-matched patients.

Institution of localized high-frequency electrical stimulation targeting early myocardial infarction: Effects on left ventricle function and geometry

BACKGROUND

Although strategies have focused on myocardial salvage/regeneration in the context of an acute coronary syndrome and a myocardial infarction (MI), interventions targeting the formed MI region and altering the course of the post-MI remodeling process have not been as well studied. This study tested the hypothesis that localized high-frequency stimulation instituted within a formed MI region using low-amplitude electrical pulses would favorably change the trajectory of changes in left ventricle geometry and function.

METHODS

At 7 days following MI induction, pigs were randomized for localized high-frequency stimulation (n = 5, 240 bpm, 0.8 V, and 0.05 ms pulses) or unstimulated (n = 6). Left ventricle geometry and function were measured at baseline (pre-MI) and at 7, 14, 21, and 28 days post-MI using echocardiography. MI size at 28 days post-MI was determined by histochemical staining and planimetry.

RESULTS

At 7 days post-MI and before randomization to localized high-frequency stimulation, left ventricular ejection fraction and end-diastolic volume was equivalent. However, when compared with 7-day post-MI values, left ventricle end-diastolic volume increased in a time-dependent manner in the MI unstimulated group, but the relative increase in left ventricle end-diastolic volume was reduced in the MI localized high-frequency stimulation group. For example, by 28 days post-MI, left ventricle end-diastolic volume increased by 32% in the MI unstimulated group but only by 12% in the MI localized high-frequency stimulation group (P < .05). Whereas left ventricular ejection fraction appeared unchanged between MI groups, estimates of pulmonary capillary wedge pressure, a marker of adverse left ventricle performance and progression to failure, increased by 62% in the MI unstimulated group and actually decreased by 17% in the MI localized high-frequency stimulation group when compared with 7-day post-MI values (P < .05). MI size was equivalent between the MI groups, indicative of no difference in the extent of absolute myocardial injury.

CONCLUSIONS

The unique findings from this study are 2-fold. First, targeting the MI region following the resolution of the acute event using a localized stimulation approach is feasible. Second, localized stimulation modified a key parameter of adverse post-MI remodeling (dilation) and progression to heart failure. These findings demonstrate that the MI region itself is a modifiable tissue and responsive to localized electrical stimulation.

Does Preoperative Troponin Level Impact Outcomes After Coronary Artery Bypass Grafting?

BACKGROUND

As a marker of myocardial injury, troponin level correlates with adverse outcomes after myocardial infarction (MI). We hypothesized that patients with a higher preoperative troponin level would have increased morbidity and mortality after coronary artery bypass grafting (CABG).

METHODS

Preoperative troponin measurements were available for 1,272 patients who underwent urgent or emergent isolated CABG at our institution from 2002 to 2016. Logistic regression assessed the risk-adjusted effect of peak troponin level on morbidity and mortality. Long-term survival analysis was performed with Kaplan-Meier and Cox proportional hazards models.

RESULTS

Preoperative troponin was positive in 835 patients (65.6%). The median peak troponin for this group was 3.2 ng/mL (interquartile range, 0.6 to 11.9 ng/mL), with a median time from peak troponin to the operation of 3 days (interquartile range, 1 to 4 days). Positive troponin was associated with more significant comorbid conditions and more extensive coronary artery disease. Operative mortality (3.7% versus 1.1%, p = 0.009), major morbidity (11.7% versus 3.9%, p < 0.001), and long-term mortality (median survival 12.5 years versus 13.6 years, p = 0.01) were increased in the positive troponin group. After risk adjustment, positive troponin was not independently associated with increased operative mortality (odds ratio, 2.61; p = 0.053). Adjusted and unadjusted analysis showed the peak preoperative troponin level did not independently predict death at any time point (all odds ratios, 1.0; p > 0.05).

CONCLUSIONS

A positive preoperative troponin correlates with worse outcomes after CABG, but risk adjustment eliminates much of the short-term predictive value of this biomarker. Peak troponin level does not influence outcomes after CABG and is a poor predictor of events when The Society of Thoracic Surgeons predictive models are used.

Optimal Timing of Surgical Revascularization for Myocardial Infarction and Left Ventricular Dysfunction

Background:

The optimal timing of surgical revascularization for patients presenting with ST-segment elevation myocardial infarction (STEMI) and impaired left ventricular function is not well established. This study aimed to examine the timing of surgical revascularization after STEMI in patients with ischemic heart disease and left ventricular dysfunction (LVD) by comparing early and late results.

Methods:

From January 2003 to December 2013, there were 2276 patients undergoing isolated coronary artery bypass grafting (CABG) in our institution. Two hundred and sixty-four (223 male, 41 females) patients with a history of STEMI and LVD were divided into early revascularization (ER, <3 weeks), mid-term revascularization (MR, 3 weeks to 3 months), and late revascularization (LR, >3 months) groups according to the time interval from STEMI to CABG. Mortality and complication rates were compared among the groups by Fisher's exact test. Cox regression analyses were performed to examine the effect of the time interval of surgery on long-term survival.

Results:

No significant differences in 30-day mortality, long-term survival, freedom from all-cause death, and rehospitalization for heart failure existed among the groups (P > 0.05). More patients in the ER group (12.90%) had low cardiac output syndrome than those in the MR (2.89%) and LR (3.05%) groups (P = 0.035). The mean follow-up times were 46.72 ± 30.65, 48.70 ± 32.74, and 43.75 ± 32.43 months, respectively (P = 0.716). Cox regression analyses showed a severe preoperative condition (odds ratio = 7.13, 95% confidence interval 2.05–24.74, P = 0.002) rather than the time interval of CABG (P > 0.05) after myocardial infarction was a risk factor of long-term survival.

Conclusions:

Surgical revascularization for patients with STEMI and LVD can be performed at different times after STEMI with comparable operative mortality and long-term survival. However, ER (<3 weeks) has a higher incidence of postoperative low cardiac output syndrome. A severe preoperative condition rather than the time interval of CABG after STEMI is a risk factor of long-term survival.

Timing of coronary artery bypass surgery in patients with non-ST-segment elevation myocardial infarction and postoperative outcomes

INTRODUCTION

The aim of the study was to assess whether a cardiac troponin T (cTnT) level 1 ng/ml or below threshold is safe and to evaluate mid-term follow-up results in stable patients with non-ST-segment elevation after acute myocardial infarction.

MATERIAL AND METHODS

Among cTnT positive patients who presented to the emergency unit with chest pain and received coronary angiography, 100 patients who underwent isolated coronary artery bypass grafting (CABG) constituted the study group (group 1). The same number of patients (n = 100) who were cTnT negative and underwent an isolated CABG operation under elective conditions were selected as the control group (group 2).

RESULTS

Among preoperative criteria, group 1 had significantly higher smoking rates (74% vs. 41%, p = 0.0001), and significantly lower ejection fraction values (47.1 ±8.25, 54.69 ±8.73, p = 0.0001). There were no significant differences between the groups with respect to operative parameters. Postoperative follow-up periods were significantly longer in group 1 (23.25 ±14 vs. 17.55 ±7.95 months, p = 0.001). Average waiting time for cTnT to drop below the 1 ng/ml threshold value was 5.73 ±2.95 (1-12) days. Intra-aortic balloon pump use in Groups 1 and 2 was 3% and 1%, respectively. There were no hospital mortalities in either group. Mortality rates at mid term were 6% in both groups.

CONCLUSIONS

This study compared two groups positive and negative for preoperative cTnT. The findings show that it is safe to wait until cTnT levels decrease to the 1 ng/ml threshold value in cTnT positive patients having a stable course. This waiting period is not very long, which is significant with respect to potential complications.

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

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 P2Y12 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.

Does early coronary artery bypass surgery improve survival in non-ST acute myocardial infarction?

A best evidence topic was written according to a structured protocol. Lack of evidence exists regarding the optimal timing for coronary artery bypass graft (CABG) surgery after non-ST myocardial infarction (NSTEMI). While some authors address the importance of the timing of surgery alone, others take into account the extent of myocardial damage. The question addressed was whether early or late CABG surgery improves hospital mortality and cardiovascular events after NSTEMI in stable patients. Using a designated search strategy, 459 articles were found, of which seven represented the best available evidence. All of these studies were level 3 (retrospective cohort studies). Studies could be divided into those which assessed CABG outcome based on preoperative cardiac troponin I (cTnI) level as a measure of the extent of myocardial damage and those which considered only the timing after myocardial infarction. Outcome measures included short-term survival, hospital mortality, length of hospital stay and major adverse cardiovascular events (MACEs). The biggest retrospective study analysing postoperative outcomes based on the timing of surgery after NSTEMI concluded that operative mortality is higher when surgery is performed within 6 h of the event. After 6 h, mortality is similar at any timepoint after 6h of NSTEMI. While other smaller studies agree that there are fewer postoperative complications when surgery is performed after 48 h of the event, no consensus is found regarding mortality between early (less than 48 h) and late CABG surgery. Taking into account preoperative cTnI values, CABG has a higher incidence of MACEs and hospital mortality in patients with cTnI >0.15 ng/ml. When surgery is performed within 24 h of symptoms, preoperative cTnI >0.72 ng/ml is associated with worse outcomes. In view of the methodological limitations and level of evidence of the studies included, it appears that surgery may be safely performed in NSTEMI patients at any time after the first 6 h of the event in patients with cTnI <0.15 ng/ml, whereas in those patients with higher values of cTnI, waiting for cTnI to reduce before considering surgery seems to be a wise option in order to decrease the incidence of MACEs and hospital mortality.

Optimal timing of coronary artery bypass grafting in acute myocardial infarction

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.

Long term results of ST-segment elevation myocardial infarction versus non-ST-segment elevation myocardial infarction after off-pump coronary artery bypass grafting: propensity score matching analysis

There is no consensus as to which acute myocardial infarction subtype poses a greater risk after coronary artery bypass grafting (CABG). We compared the early and the long term results of off-pump coronary artery bypass grafting (OPCAB) between patients with STEMI (group I, n = 83), and NSTEMI (group II, n = 237). Group I had higher EuroSCORE, prevalence of emergency surgery, preoperative intra-aortic balloon pump use, preoperative emergency percutaneous transluminal coronary angioplasty, and preoperative thrombolytic use than group II. There were no significant differences in 30-day mortality and major adverse cardiac and cerebrovascular event (MACCE) between groups. Overall 8-yr survival was 93% and 87% in groups I and II, respectively. Freedom from MACCE after 8 yr was 92% and 93% in groups I and II, respectively. After propensity score matching analysis, there were no significant differences in preoperative parameters, postoperative in-hospital outcomes, and long-term clinical outcomes. Surgical results of OPCAB in patients with acute myocardial infarction show good results in terms of long-term survival and freedom from MACCE, with no significant differences in clinical outcomes between STEMI and NSTEMI groups.

Risk stratification in acute coronary syndromes

Accurate and readily available systems for risk stratification and a wide array of antithrombotic agents, on top of classical anti-ischemic drugs, provide the noninvasive cardiologist admitting the patient in the CCU with an effective and reliable armamentarium for the safe management of most patients with ACS. From the interventionalist's perspective, the immediate knowledge of the coronary anatomy yields the most valuable information to address the most appropriate treatment. The sooner angiography is performed the higher the benefit for patients at moderate to high risk, but if performed by expert teams and with the correct use of modern drugs and devices, the invasive approach has the potential to reduce costs and length of hospital stay also in low-risk patients. Although still some reluctance remains to equalize treatment strategies for patients with STEMI to those with NSTEMI, such differences will likely disappear in the near future with upcoming new evidence. Cardiac surgery may represent a life-saving alternative for patients presenting with NSTEMI evolving in cardiogenic shock or with mechanical complications, or in patients unsuitable for PCI or with failed PCI attempts. In stabilized conditions after the treatment of the culprit lesion, patients with severe multivessel disease may benefit from cardiac surgery to complete myocardial revascularization. Indications for CABG in this setting should be evaluated in the context of a local "heart team" or through prespecified protocols in centers without cardiac surgery on site.

Off-pump versus on-pump coronary artery bypass grafting in acute coronary syndrome: a clinical analysis

Background

Although off-pump coronary artery bypass (OPCAB) surgery has many beneficial effects compared with on-pump surgery, switch to on-pump surgery has significantly higher risks of operative mortality. Benefits of OPCAB over on-pump surgery strategies concerning myocardial revascularization are still debatable. We have aimed to develop an "algorithm of off-pump surgical strategy" on preventing conversion to on-pump. This clinical study reports our clinical outcome of OPCAB in patients with acute coronary syndrome.

Methods

Between January 2006 and December 2008, 198 patients with acute coronary syndrome were enrolled in the study. Decision of OPCAB (142 patients) or on-pump surgery (56 patients) was made according to patients' present clinical status and our surgical background. Cardiac enzymes, duration of the surgery, graft numbers, stay in intensive care unit were recorded.

Results

OPCAP group has shorter operation time (82.78 min versus 164.22 min, p < 0.001), lesser necessity for intra-aortic balloon pumping (3.5% versus 12.5%, p = 0.053), shorter duration of intensive care unit stay (p < 0.05) and hospital stay (p < 0.001) compared to on-pump patients. EuroSCORE level was lower in OPCAP group (p < 0.001). None of the patients of OPCAB group required conversion to on-pump technique.

Conclusions

The patients who admitted to the hospital with acute coronary syndrome within "golden hours" (within 6 hours after onset) had a greater chance for OPCAB surgery. This study proves that EuroSCORE is likely to be an important factor in deciding which surgical technique to use, but a further investigation is needed to verify. According to our findings, a careful evaluation of coronary angiography, hemodynamic status, quality of target coronary vessel and timing of surgery are important for OPCAB surgery to avoid conversion to on-pump. By a careful systematic evaluation of the patients as explained with this article, it can be prevent or reduce conversion to on-pump surgery during OPCAB surgery.

Timing of revascularization after acute myocardial infarction

The optimal timing of surgical revascularization after acute myocardial infarction remains controversial. Higher mortality after emergency coronary artery bypass has been documented. We retrospectively reviewed 278 patients who underwent coronary artery bypass between 2005 and 2007. The time from onset of myocardial infarction to surgical revascularization was the basis for dividing patients into 3 groups: surgery was performed within 24 h in group 1, at 24-72 h in group 2, and after 14 days in group 3. There was a definite relationship between the timing of revascularization and the outcome of surgery. Group 1 had a mortality rate of 11.7%, group 2 had 7% mortality, and group 3 had 2.5% mortality. Group 1 had the highest incidence of postoperative complications. Surgical revascularization within 24 h of acute myocardial infarction was associated with significantly higher risks of mortality and morbidity than procedures performed after 72 h.

Preoperative cardiac troponin I to assess midterm risks of coronary bypass grafting operations in patients with recent myocardial infarction

BACKGROUND

The optimal timing for coronary artery bypass grafting (CABG) in patients with recent acute myocardial infarction (AMI) is unclear. Cardiac troponin I (cTnI) is a widely accepted biomarker of myocardial damage. The objective of this study was to determine whether preoperative cTnI values could be used to determine risk stratification for CABG operations in patients with recent AMI.

METHODS

Evaluated were 184 patients who sustained an AMI within 21 days of undergoing nonurgent CABG operations. They were divided into two groups according to their preoperative cTnI values: 117 patients with cTnI of 0.15 ng/mL or less and 67 with cTnI exceeding 0.15 ng/mL. Associations between study variables and events were assessed with logistic regression modelling. Time from AMI to operation was evaluated to define preoperative cTnI variation.

RESULTS

Values of cTnI tended to decrease when the interval between AMI and the operation increased. Preoperative cTnI values were significantly associated with a higher incidence of major postoperative complications (low cardiac output syndrome, intraaortic balloon pump necessity, mechanical ventilation >72 hours, acute renal failure, in-hospital mortality). Perioperative myocardial damage was more pronounced in patients with cTnI exceeding 0.15 ng/mL. Multivariate analyses revealed cTnI exceeding 0.15 ng/mL was an independent predictor for 6-month mortality (odds ratio, 3.7; p = 0.043).

CONCLUSIONS

Preoperative cTnI exceeding 0.15 ng/mL in patients with recent AMI undergoing CABG is associated with higher postoperative myocardial damage and is a strong determinant of postoperative morbidity and mortality within the 6-month period.

Timing of nonemergent coronary artery bypass grafting and mortality after non-ST elevation acute coronary syndrome

BACKGROUND

The purpose of this study was to determine the association between time to coronary artery bypass grafting (CABG) and mortality among patients admitted with non-ST elevation acute coronary syndrome (NSTEACS). Patients are increasingly being referred for CABG soon after NSTEACS, although few data exist to guide the optimal timing of bypass surgery.

METHODS

We identified a cohort of all patients who underwent nonemergent CABG within 60 days of hospitalization for NSTEACS in the province of Alberta, Canada, from 2000 to 2004. Time from admission to CABG was categorized as early (2-7 days), intermediate (8-14 days), or late (15-60 days-reference group). The primary outcome was mortality occurring within 30 days of surgery.

RESULTS

Of the total cohort of 1,454 patients, 213 (14.6%) underwent early, 637 (43.8%) underwent intermediate, and 707 (48.6%) underwent late CABG surgery. In the final adjusted model time to CABG was not statistically significant as an independent predictor of short-term mortality. Compared to late CABG, there was a nonsignificant increased risk of mortality for those undergoing early (hazard ratio 2.36, 95% CI 0.72-7.76) and intermediate (hazard ratio 1.68, 95% CI 0.76-3.72) CABG surgery.

CONCLUSIONS

Time from admission to CABG was not associated with an increased risk of short-term mortality. However, there was a trend toward increased mortality with early CABG, and this study does not exclude the presence of a modest risk association between timing of CABG and short-term mortality.

Surgical ventricular reconstruction with different myocardial protection strategies. A propensity matched analysis

The aim of this study is to compare outcomes of patients undergoing surgical ventricular reconstruction (SVR) with normothermic cardiopulmonary bypass (CPB) and beating heart or hypothermic CPB and cardioplegic arrest. Between 2001 and 2008, 588 patients underwent SVR. A propensity score matching was performed and 91 matched pairs were created: group 1 (G1) operated with normothermic CPB and beating-heart technique, and group 2 (G2) operated with hypothermic CPB and cardioplegic arrest. Mean age was 62+/-9 years in G1 and 63+/-10 years in G2 [not significant (NS)]. Average follow-up was 42.7+/-26 months (range 1-72). Major cardiac and cerebro-vascular events (MACCE) were assessed. Thirty-day mortality was 4% in G1 and 5% in G2 (NS). Kaplan-Meier survival at six years was 79+/-4% and 72+/-9% (NS) and freedom from MACCE was 82+/-4% and 83+/-7% in G1 and G2, respectively (NS). Left ventricular volume reduction, ejection fraction and New York Heart Association (NYHA) class improvement were significant in the overall population; no significant differences were found between groups. The following independent risk factors for cardiac death were identified: mitral valve regurgitation, surgery <3 months from myocardial infarction, NYHA class III-IV. This study showed that outcomes following SVR are not affected by myocardial protection strategies neither in cardiac function and clinical status nor in survival.

Timing of bypass surgery in stable patients after acute myocardial infarction

OBJECTIVES

To determine the optimal timing for bypass surgery in stable patients after acute myocardial infarction (MI).

BACKGROUND

Coronary artery bypass graft surgery (CABG) is a proven treatment for coronary artery disease. Because of the hypothesized risk of hemorrhagic transformation, it had become common practice to wait four to six weeks after MI. Recently, improvements in surgical and perioperative management, as well as an increase in pre-CABG in-hospital waiting times and excess burden on health care resources, have pushed surgeons to operate earlier. The optimal timing for a stable patient to undergo CABG after MI is unclear, because there have been no randomized trials to answer this question.

METHODS

The published literature comparing early versus late surgical revascularization procedures in stable post-MI patients was reviewed.

RESULTS

No randomized, prospective trials were found; however, several retrospective studies were identified. Most series examining Q wave MIs showed that mortality is higher in the early stages post-MI and progressively decreases with time post-MI. When studies examined non-Q wave MIs separately, there appeared to be less of a mortality difference between early and late surgical revascularization. There was a large disparity between the definitions of early surgery post-MI among the studies, some as early as 6 h and others up to eight days. Factors that increased mortality include abnormal left ventricular function and urgency of surgery, and some studies found risk models helpful to define increased risk after infarction. The possible increased risk of early surgery may be balanced against the potential for improved remodelling, improved quality of life and decreased hospital stay costs.

CONCLUSIONS

There is a need for a randomized, prospective trial examining the optimal timing for CABG in stable post-MI patients.