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Appropriate timing of coronary artery bypass grafting after acute myocardial infarction
Alexander Assmann1, Udo Boeken, Payam Akhyari
1Department of Cardiovascular Surgery, Medical Faculty, University Duesseldorf, Duesseldorf, Germany.
Insights
Coronary artery bypass grafting (CABG) within 10 days of acute myocardial infarction (AMI) increases mortality, particularly in high-risk patients. Delaying surgery beyond 10 days, especially for elderly patients or those with low ejection fraction, improves outcomes.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Critical Care Medicine
Background:
- The optimal timing for coronary artery bypass grafting (CABG) after acute myocardial infarction (AMI) is debated, with recommendations varying from immediate intervention to delayed surgery.
- High-risk patient groups, including the elderly and those with impaired left ventricular function, face compounded mortality risks, necessitating focused analysis.
Purpose of the Study:
- To determine the appropriate timing for CABG following AMI.
- To specifically evaluate the impact of timing on high-risk patients (age >70 years, LVEF <30%).
Main Methods:
- Retrospective analysis of 3475 patients undergoing isolated CABG (2005-2009).
- 1168 patients with AMI within 30 days were categorized by surgical delay: <6h, 6h-1d, 2-3d, 4-10d, 11-20d, 21-30d.
- Subgroup analyses were performed for patients >70 years or with LVEF <30%.
Main Results:
- Mortality rates significantly increased for CABG performed within 10 days post-AMI compared to surgery without prior infarction (1.9%).
- In high-risk subgroups (age >70 or LVEF <30%), significantly elevated mortality persisted for CABG within 20 days post-AMI.
- Multivariate analysis identified CABG within 10 days of AMI and age over 60 as independent predictors of operative mortality.
Conclusions:
- Early CABG (<10 days) after AMI is associated with significantly increased operative mortality.
- This increased risk is particularly pronounced in elderly patients and those with severely impaired left ventricular ejection fraction.
- A delay of at least 3 days post-AMI is recommended when hemodynamic stability permits, to mitigate surgical risks.
Objectives:
Optimal timing of coronary artery bypass grafting (CABG) after acute myocardial infarction (AMI) remains the subject of fierce debate. Therefore, the recommended deferral ranges from immediate intervention to surgery 4 weeks after infarction. Especially, the increasing cohorts of patients at old age or with poor left ventricular function, whose mortality rates are additionally enhanced, may profit from focused analyses. This study aims at clarifying the appropriate timing of CABG after AMI, with special regard to high-risk patients (Age >70 years, left ventricular ejection fraction (LVEF) <30%).
Methods:
Retrospective analysis was performed in 3475 patients who had undergone isolated CABG between 2005 and 2009. Those 1168 patients with previous AMI (<30 days) were categorized in groups, depending on deferral of surgery: <6 hours after AMI (A), 6 hours-1 day (B), 2-3 days (C), 4-10 days (D), 11-20 days (E), and 21-30 days (F). Furthermore, subgroups with an age >70 years or a LVEF <30% were examined.
Results:
The mortality rates in groups A-F were 14.8, 10.2, 8.8, 4.2, 2.3, and 2.0%, whereas only the values of groups A-D were significantly increased versus the mortality rate of patients without previous AMI (1.9%). In patients over 70 years, we observed operative mortalities of 26.3, 14.3, 11.9, 6.1, 4.2, and 3.1% (groups A-F) versus 2.5% (no previous AMI), while 27.4, 15.4, 11.7, 6.0, 3.7, and 2.8% (groups A-F) versus 2.7% (no previous AMI) of patients with a LVEF <30% died during the first 30 days after surgery. In both subanalyses of high-risk patients, the enhanced mortalities of groups A-E reached significance. Multivariate analysis of operative risk factors revealed that CABG within 10 days after AMI and age over 60 years are independently associated with operative mortality.
Conclusions:
CABG early after AMI (<10 days) is accompanied by significantly increased mortality, especially in elderly patients or in patients with a severely impaired LVEF. At least the critical time period of 3 days should be avoided-whenever the hemodynamics is stable enough.
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