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Ketorolac improves graft patency after coronary artery bypass grafting: a propensity-matched analysis
Milo Engoren1, Jonathan Hadaway, Thomas A Schwann
1Department of Anesthesiology, Mercy St. Vincent Medical Center, Toledo, Ohio 43608, USA. engoren@pol.net
Insights
Ketorolac use after coronary artery bypass grafting (CABG) was linked to better survival. This study found ketorolac also reduced graft occlusion, potentially explaining the survival benefit.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Ketorolac, a cyclooxygenase-1 inhibitor, use in cardiac surgery is debated due to cardiovascular event concerns.
- Previous research suggested improved survival with ketorolac post-coronary artery bypass grafting (CABG).
Purpose of the Study:
- To investigate the association between postoperative ketorolac use and graft occlusion rates after CABG.
- To explore if improved graft patency explains the survival benefit of ketorolac.
Main Methods:
- Retrospective study of patients undergoing coronary arteriography for recurrent ischemic heart disease symptoms.
- Propensity score matching was used to compare ketorolac users and non-users.
- Graft occlusion rates and time to occlusion were analyzed using Cox proportional hazard modeling.
Main Results:
- While overall graft occlusion rates were similar, ketorolac users experienced a significantly longer time to angiographically proven occlusion (2.80 vs 2.04 years).
- Ketorolac use was associated with a reduced hazard ratio (0.561) for any graft occlusion, indicating nearly a halving of the risk.
- Propensity-matched analysis confirmed the association between ketorolac and lower graft occlusion risk.
Conclusions:
- Post-CABG ketorolac use is associated with a lower rate of angiographically proven graft closure.
- Improved graft patency may be a key mechanism underlying the observed survival benefit of ketorolac in CABG patients.
Background:
The use of ketorolac, a potent cyclooxygenase-1 inhibitor, for analgesia after cardiac operations has been limited by concerns of increased cardiovascular events. However, a recent study found that its use after coronary artery bypass grafting was associated with improved survival.
Methods:
This was a retrospective study of patients who received coronary arteriograms for symptoms suggestive of recurrent ischemic heart disease. Patients who received postoperative ketorolac were matched with nonusers by propensity scores. Graft occlusion rates were compared, and their association with ketorolac use was compared using Cox proportional hazard modeling.
Results:
Although the rate of graft occlusion was similar in the two groups, in 184 of the 303 propensity-matched patients (61%) who received ketorolac vs 202 of the 303 patients (67%) who did not (p=0.13), there was a longer time to angiographically proven occlusion in the patients who received ketorolac (2.80±2.19 vs 2.04±1.63 years; p<0.001). Cox modeling to control for the other variables and the longer time to angiography in the ketorolac group showed that ketorolac use was associated with nearly a halving of the hazard ratio (0.561; 95% confidence interval, 0.454 to 0.692; p<0.001) for any graft occlusion.
Conclusions:
The use of ketorolac after coronary artery bypass grafting was associated with a lower rate of angiographically proven graft closure and suggests a mechanistic (improved graft patency) explanation for the previously reported survival benefit of ketorolac.
