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Inpatient vs Delayed Readmission for Coronary Artery Bypass Grafting After Non-ST Elevation Myocardial Infarction
Michael A Catalano1, Yu Zhao2, Omar Toubat1
1Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Insights
Optimal timing for coronary artery bypass grafting (CABG) after non-ST-elevation myocardial infarction (NSTEMI) is 2-4 days post-diagnosis. Inpatient CABG is generally preferred over delayed surgery due to lower mortality risks.
Area of Science:
- Cardiology
- Cardiac Surgery
- Health Services Research
Background:
- The optimal timing for coronary artery bypass grafting (CABG) following non-ST-elevation myocardial infarction (NSTEMI) is not well-established.
- National practice patterns and outcomes for CABG timing after NSTEMI require further investigation.
Purpose of the Study:
- To assess national practice patterns and outcomes of CABG timing following NSTEMI.
- To compare inpatient versus delayed CABG strategies and analyze specific inpatient timing.
Main Methods:
- A retrospective analysis of Medicare beneficiaries (≥65 years) with NSTEMI undergoing diagnostic angiography (10/2016-10/2021).
- Propensity-score matching compared inpatient CABG with delayed elective CABG within three months.
- Primary endpoint: 30-day mortality; Secondary endpoint: 4-year survival. Logistic regression with natural cubic splines analyzed inpatient CABG timing (0-1, 2-3, 4-7, >7 days).
Main Results:
- Out of 704,638 patients, 27.1% underwent inpatient CABG and 2.3% had delayed elective CABG.
- Propensity-matched analysis showed lower 30-day mortality for delayed elective CABG (3.6% vs. 4.9%, p<0.001), but similar 4-year survival.
- Among discharged patients, 1.3% required urgent CABG (30-day mortality=6.3%), and 9.1% died within three months without revascularization.
- Inpatient CABG demonstrated optimal short-term outcomes when performed 2-4 days post-angiography.
Conclusions:
- Performing CABG 2-4 days after NSTEMI diagnosis is associated with optimal outcomes.
- While delayed elective CABG shows short-term survival benefits in selected patients, most NSTEMI patients benefit from inpatient revascularization due to risks of mortality and urgent intervention after discharge.
Background:
The optimal timing of coronary artery bypass grafting (CABG) after non-ST elevation myocardial infarction (NSTEMI) remains debated. We assessed national practice patterns and outcomes of CABG timing after NSTEMI, including inpatient vs delayed surgery, and specific timing of inpatient surgery.
Methods:
Medicare beneficiaries aged ≥65 years presenting nonelectively with NSTEMI who underwent diagnostic angiography from October 2016 to October 2021 were identified. Patients undergoing percutaneous coronary intervention during the index admission and those who died before any revascularization were excluded. Patients undergoing inpatient CABG were compared with those discharged and returning for elective CABG within 3 months using propensity score matching, with a primary end point of 30-day mortality and a secondary end point of 4-year survival. Among inpatient CABG patients, 30-day mortality of patients undergoing intervention at 0 to 1, 2 to 3, 4 to 7, and >7 days after diagnosis was assessed with logistic regression with natural cubic splines.
Results:
Of 704,638 patients with NSTEMI who underwent angiography, 90,551 (27.1%) underwent inpatient CABG and 5715 (2.3%) returned for elective CABG. After propensity matching, 30-day mortality was lower with elective readmission (3.6% vs 4.9%, P < .001), although 4-year survival was similar (P = .553). Among discharged patients, 1.3% required urgent CABG (30-day mortality of 6.3%) and 9.1% died without revascularization within 3 months. Among inpatient CABG patients, optimal short-term outcomes were observed at 2 to 4 days after angiography.
Conclusions:
Optimal CABG outcomes after NSTEMI occur when surgery is performed 2 to 4 days after diagnosis. Although delayed elective CABG offers short-term survival advantages in highly-selected patients, the risk of mortality and urgent intervention in discharged patients suggest most should undergo inpatient revascularization.
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