Surgical revascularization and perioperative management in patients with non-ST-elevation acute coronary syndromes

The management and surgical revascularization treatment of patients with acute coronary syndromes (ACS) have undergone great evolution over the past decade. The objective of the present study was therefore to analyze the outcome and predictors of survival in patients unresponsive to maximal non-surgical treatment referred to emergency coronary artery bypass grafting (CABG) with ACS.

Between October 1999 and September 2004, a total of 3571 CABG patients underwent primary isolated CABG at our institution. Out of these, non-ACS (N-ACS) was present in 3124 patients (group 1), 386 patients (group 2) had non-ST-elevation ACS (NSTE-ACS), whereas 61 patients (group 3) had ST-elevation ACS (STE-ACS). Clinical data, in-hospital morbidity and mortality were prospectively recorded and studied retrospectively in the groups.

Left main stem stenosis was observed in 25%, 32%, and 41%, respectively (P<0.02). Previous myocardial infarction was found in 33%, 43%, and 73% (P<0.001). Overall in-hospital mortality was 1.5% in group 1, 4.2% in group 2, and 13.0% in group 3 (P< 0.001). Logistic regression and receiver operating characteristic analyses identified cTnI as the strongest preoperative predictor significantly related to in-hospital mortality. A preoperative cTnI level above 1.5 ng/ml was the best single predictor for in-hospital mortality amongst patients with ACS.

The present study clearly demonstrates a significant difference of in-hospital morbidity and mortality between patients with ACS undergoing CABG. A more precise patient's risk stratification on admission and improvements in the perioperative management with adjunctive pharmacological therapies and the use of intraaortic balloon counter pulsation may improve patients' outcome.