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Percutaneous revascularization improves outcomes in patients with prior coronary artery bypass surgery
Gabor Gyenes1, Colleen M Norris, Michelle M Graham
1Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Insights
Repeat revascularization after coronary artery bypass grafting (CABG) is less common but associated with improved survival. Percutaneous coronary intervention (PCI) benefits both diabetic and non-diabetic patients, supporting its use in post-CABG individuals, especially those with acute coronary syndromes (ACS).
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Outcomes Research
Background:
- Coronary artery bypass surgery (CABG) guidelines suggest a low threshold for catheterization.
- Repeat revascularization post-CABG is often perceived as unfeasible, with limited outcome data.
- Clinical practice may not align with guidelines due to perceived challenges and scarce evidence.
Purpose of the Study:
- To analyze repeat catheterization, revascularization, and mortality rates in patients with prior CABG.
- To compare outcomes of post-CABG patients with those without prior CABG.
- To evaluate the impact of percutaneous coronary intervention (PCI) on mortality in post-CABG patients, including those with diabetes.
Main Methods:
- Utilized the APPROACH clinical data initiative in Alberta, Canada.
- Analyzed non-emergency repeat catheterization and revascularization rates in patients with previous CABG.
- Grouped patients by indication (acute coronary syndromes [ACS], stable angina [SA]) and compared to a cohort without prior CABG.
Main Results:
- 31.5% and 11% of post-CABG patients received PCI or reoperation, respectively.
- Post-CABG patients were more likely to be managed medically (57.5%) compared to the overall cohort (41.5%).
- PCI was linked to a 19% adjusted mortality reduction over 14 years, with similar benefits observed in diabetic patients.
Conclusions:
- Repeat revascularization is less frequent in post-CABG patients but associated with improved mortality.
- Percutaneous coronary intervention (PCI) demonstrates mortality benefits for both diabetic and non-diabetic post-CABG patients.
- These findings support pursuing revascularization, particularly PCI, in post-CABG patients, especially those presenting with ACS.
Background:
Although ACC/AHA guidelines recommend a low threshold for catheterization after coronary artery bypass surgery (CABG), in clinical practice repeat revascularization often appears unfeasible and data on outcomes are scarce.
Methods:
Using APPROACH, a clinical data collection and outcome monitoring initiative in Alberta, Canada, we analyzed nonemergency repeat catheterization, revascularization, and mortality rates of all patients with previous CABG, grouped by indication (acute coronary syndromes [ACS], stable angina [SA]) and compared to those of the cohort without previous CABG.
Results:
Of 7,127 patients, 31.5%, and 11% received percutaneous revascularization (PCI), or reoperation, respectively. Significantly more post-CABG patients were managed medically as compared with the overall APPROACH cohort of coronary disease patients (57.5% vs. 41.5%-P < 0.001). Post CABG patients with ACS received PCI more often than those with SA (36.4% vs. 24.8%). PCI was associated with improved both non-adjusted and adjusted mortality by 22 and 19%, respectively (P < 0.001) during a follow-up of up to 14 years. Patients with diabetes had a higher mortality rate than those without at 1-, 5-, and 10-year follow-up in every treatment group. However PCI was associated with a similar improvement in mortality (HR: 0.76 [95% SD: 0.65-0.90]) in diabetic patients (HR: 0.85 [95% SD: 0.75-0.96]) when compared to medical management.
Conclusion:
Significantly fewer post-CABG patients received repeat revascularization than all-comers however; PCI was associated with improved mortality in both the diabetic and the nondiabetic patient population. These findings support the practice of attempting revascularization in post-CABG patients, particularly in those with an ACS.
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