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Published on: September 15, 2023
Prior coronary artery bypass graft patients with ST-segment elevation myocardial infarction treated with primary
Robert C Welsh1, Christopher B Granger, Cynthia M Westerhout
1University of Alberta, Edmonton, Alberta, Canada.
Insights
Patients with prior coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) have worse outcomes. These patients experienced less reperfusion and higher 90-day mortality, particularly when the infarct-related artery was a bypass graft.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Limited data exists on procedural success and clinical outcomes for ST-segment elevation myocardial infarction (STEMI) patients with prior coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention (PCI).
- Understanding these outcomes is crucial for optimizing treatment strategies in this complex patient population.
Purpose of the Study:
- To compare procedural success and 90-day clinical outcomes in STEMI patients undergoing primary PCI, stratified by the presence or absence of prior CABG.
- To identify specific factors influencing outcomes in STEMI patients with prior CABG.
Main Methods:
- Analysis of data from the APEX-AMI trial, a randomized, placebo-controlled study of pexelizumab in STEMI patients undergoing primary PCI.
- Comparison of clinical/procedural characteristics, culprit vessel (infarct-related artery [IRA]), and 90-day outcomes between patients with and without prior CABG.
- Stratification of outcomes based on whether the IRA was a bypass graft or a native vessel.
Main Results:
- Patients with prior CABG were older, more frequently male, and had higher comorbidity and multivessel disease rates.
- Primary PCI was less frequently performed in prior CABG patients (78.9% vs. 93.9%), with lower rates of Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 restoration (82.5% vs. 91.6%).
- Prior CABG patients had significantly higher 90-day mortality (1.9-fold increased risk), especially when the IRA was a bypass graft (19% vs. 5.7% for native vessel).
Conclusions:
- STEMI patients with prior CABG undergoing primary PCI experience reduced acute reperfusion rates and poorer angiographic outcomes.
- These patients face a substantially higher risk of 90-day mortality, particularly when the infarct-related artery is a bypass graft.
- Findings highlight the need for tailored management strategies for STEMI patients with prior CABG, considering the IRA status.
Objectives:
We sought to compare outcomes in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) with or without previous coronary artery bypass grafts (CABG).
Background:
Limited information exists regarding procedural success and clinical outcomes of STEMI patients with CABG undergoing primary PCI.
Methods:
The APEX-AMI (Assessment of Pexelizumab in Acute Myocardial Infarction) trial was a randomized, placebo-controlled trial of pexelizumab in STEMI patients with planned primary PCI: 128 of 5,745 (2.2%) patients had prior CABG. Clinical/procedural characteristics, culprit vessel (infarct-related artery [IRA]), and 90-day clinical outcomes were compared.
Results:
Patients with previous CABG were more frequently men, older, had a higher incidence of comorbidities and multivessel disease. In patients with versus without prior CABG, PCI was performed less frequently, that is, 78.9% versus 93.9%; of those with prior CABG receiving PCI, Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 was also restored less often, that is, 82.5% versus 91.6% (both p < 0.001). In prior CABG, there was a nearly even designation of the IRA as a bypass graft (n = 63) versus a native vessel (n = 55): IRA post-PCI TIMI flow grade 3 was achieved in 66.7% versus 88.0%, respectively (p = 0.043). Prior CABG patients had increased 90-day death and composite 90-day death/congestive heart failure/shock. Excess death remained significant after multivariable adjustment (hazard ratio: 1.9, 95% confidence interval: 1.08 to 3.33, p = 0.025). When prior CABG patients were stratified by the type of IRA, there was further discrimination of the increased 90-day death, that is, 19% bypass graft (n = 63) versus 5.7% native vessel (n = 55, p = 0.05), respectively.
Conclusions:
Prior CABG patients with STEMI are less likely to undergo acute reperfusion, have worse angiographic outcomes following primary PCI, and higher 90-day mortality. These findings are especially applicable when the IRA was a bypass graft.
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