Patients with non–ST-elevation acute coronary syndromes undergoing coronary artery bypass grafting in the modern era of antithrombotic therapy

• Published in: The American heart journal 2008-02, Vol.155 (2), p.239-244
• Main Authors: Chew, Derek P., MBBS, MPH, Huang, Zhen, MS, Pieper, Karen S., MS, White, Harvey, DSc, Mahaffey, Kenneth W., MD, Ferguson, James J., MD, Califf, Robert M., MD, Aylward, Philip G., MD
• Format: Article
• Language: English
• Subjects: Acute Coronary Syndrome - diagnosis; Acute Coronary Syndrome - drug therapy; Acute Coronary Syndrome - surgery; Acute coronary syndromes; Aged; Biological and medical sciences; Cardiology. Vascular system; Cardiovascular; Coronary Artery Bypass - adverse effects; Coronary Artery Bypass - mortality; Coronary heart disease; Coronary vessels; Drug therapy; Electrocardiography; Enoxaparin - therapeutic use; Female; Fibrinolytic Agents - therapeutic use; Heart; Heart attacks; Heparin - therapeutic use; Humans; Male; Medical sciences; Middle Aged; Myocardial Infarction - etiology; Myocarditis. Cardiomyopathies; Platelet Aggregation Inhibitors - therapeutic use; Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors; Postoperative Hemorrhage - etiology; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Survival Analysis; Ticlopidine - analogs & derivatives; Ticlopidine - therapeutic use; Treatment Outcome
• ISSN: 0002-8703; 1097-6744
• DOI: 10.1016/j.ahj.2007.10.002

Background Many high-risk patients with non–ST-elevation acute coronary syndromes within the SYNERGY trial required coronary artery bypass grafting (CABG) for optimal revascularization. We explored the clinical outcomes among high-risk patients undergoing CABG and the impact of modern pharmacology. Methods We evaluated180-day rates of death and myocardial infarction (MI) and 30-day GUSTO severe bleeding among patients undergoing CABG, contrasting them with patients undergoing percutaneous coronary intervention (PCI) or medical management. The relationships between perioperative MI, bleeding events, and 6-month mortality were explored. The effect of random assignment to unfractionated heparin or enoxaparin and the relationships between use of clopidogrel and glycoprotein IIb/IIIa inhibitors and clinical outcomes were assessed. Results Death or MI at 6 months was more common among patients requiring CABG (CABG 31.2%, PCI 15.9%, medical 9.9%). Thirty-day GUSTO severe bleeding was also higher (CABG 6.4%, PCI 1.1%, medical 0.9%). Perioperative MI and GUSTO severe bleeding were associated with excess 6-month mortality (hazard ratio 2.1, 95% CI 1.27-3.53 and hazard ratio 7.6, CI 4.78-12.09, respectively). Randomization to enoxaparin was not associated with an increase in bleeding or a reduction in death or MI. No differences in ischemic outcomes were observed among patients given glycoprotein IIb/IIIa inhibition or clopidogrel. Conclusions High-risk patients still commonly require CABG with greater bleeding and ischemic event rates observed. Current definitions of perioperative MI and GUSTO severe bleeding portend an increased in 6-month mortality among CABG patients. Modern pharmacotherapies do not appear to impact these higher event rates.