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Revascularization after acute myocardial infarction
L L Creswell1, M J Moulton, J L Cox
1Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
Insights
Optimal timing for coronary artery bypass grafting (CABG) after acute myocardial infarction (MI) is crucial. Elective CABG is safe early after MI, especially with intra-aortic balloon pump use for postinfarction angina.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Cardiac Surgery Outcomes
Background:
- The ideal timing for coronary artery bypass grafting (CABG) following acute myocardial infarction (MI) is a subject of ongoing debate.
- Understanding the risks associated with different time intervals between MI and CABG is essential for patient management.
Purpose of the Study:
- To evaluate the impact of varying time intervals between acute myocardial infarction (MI) and coronary artery bypass grafting (CABG) on operative mortality and morbidity.
- To assess the safety and efficacy of early elective CABG after MI.
Main Methods:
- Retrospective analysis of 3,942 patients undergoing CABG, including 2,296 post-MI patients, between 1986 and 1993.
- Comparison of operative mortality rates across different time intervals from MI to CABG.
- Analysis of outcomes for elective versus urgent/emergent CABG, with and without intra-aortic balloon pump support.
Main Results:
- Operative mortality after CABG varied significantly with time from MI, ranging from 9.1% (less than 6 hours) to 2.9% (more than 6 weeks), compared to 2.5% in non-MI patients.
- Early CABG (<14 days) was associated with increased stroke, perioperative MI, and longer hospitalization.
- For elective CABG, mortality was lower across all intervals, with 0.0% for <6 hours and 2.1% for >6 weeks.
- Intra-aortic balloon pump use in postinfarction angina patients undergoing CABG within 14 days of MI reduced mortality from 11.8% to 5.3%.
Conclusions:
- Elective CABG can be performed safely and with acceptable outcomes early after acute MI.
- Aggressive use of the intra-aortic balloon pump is recommended for patients with postinfarction angina to facilitate elective surgery.
- These findings support a strategy of early, elective CABG when feasible after acute MI, with appropriate supportive measures.
Background:
The optimal timing for coronary artery bypass grafting (CABG) after acute myocardial infarction (MI) remains controversial.
Methods:
We examined our experience retrospectively in 3,942 patients who underwent CABG between 1986 and 1993, including 2,296 patients after acute MI.
Results:
The operative mortality associated with increasing time intervals between MI and CABG were 9.1%, 8.3%, 5.2%, 6.5%, and 2.9%, for less than 6 hours, 6 hours to 2 days, 2 to 14 days, 2 to 6 weeks, and more than 6 weeks, respectively. In comparison, the operative mortality was 2.5% for patients with no history of acute MI. The incidence of permanent stroke and perioperative MI were greater and the length of postoperative hospitalization was longer for patients undergoing CABG early after MI. For patients undergoing operation electively, however, the operative mortality associated with increasing time intervals between MI and CABG were less, at 0.0%, 3.6%, 2.1%, 6.4%, and 2.1% for less than 6 hours, 6 hours to 2 days, 2 to 14 days, 2 to 6 weeks, and more than 6 weeks, respectively. For patients undergoing CABG within 14 days of MI, the operative mortality was 5.3% for those receiving an intraaortic balloon pump preoperatively for postinfarction angina, but 11.8% for those who underwent urgent/emergent operation without intraaortic balloon pump support.
Conclusions:
Elective CABG can be accomplished with acceptable morbidity and mortality early after acute MI if an elective operation is possible. In addition, the intraaortic balloon pump should be used aggressively in patients with postinfarction angina to allow for elective rather than urgent/emergent operation.