Prior Coronary Artery Bypass Graft Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

• Published in: JACC. Cardiovascular interventions 2010-03, Vol.3 (3), p.343-351
• Main Authors: Welsh, Robert C., MD, Granger, Christopher B., MD, Westerhout, Cynthia M., PhD, Blankenship, James C., MD, Holmes, David R., MD, O'Neill, William W., MD, Hamm, Christian W., MD, Van de Werf, Frans, MD, PhD, Armstrong, Paul W., MD
• Format: Article
• Language: English
• Subjects: Aged; Angioplasty, Balloon, Coronary - adverse effects; Angioplasty, Balloon, Coronary - mortality; Antibodies, Monoclonal - therapeutic use; Antibodies, Monoclonal, Humanized; Cardiovascular; Coronary Angiography; Coronary Artery Bypass - adverse effects; Coronary Artery Bypass - mortality; coronary artery bypass graft; Female; Graft Occlusion, Vascular - diagnostic imaging; Graft Occlusion, Vascular - drug therapy; Graft Occlusion, Vascular - etiology; Graft Occlusion, Vascular - mortality; Graft Occlusion, Vascular - therapy; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction - diagnostic imaging; Myocardial Infarction - drug therapy; Myocardial Infarction - etiology; Myocardial Infarction - mortality; Myocardial Infarction - therapy; percutaneous coronary intervention; Proportional Hazards Models; Risk Assessment; Risk Factors; Single-Chain Antibodies - therapeutic use; ST-segment elevation myocardial infarction; Time Factors; Treatment Outcome
• ISSN: 1936-8798; 1876-7605
• DOI: 10.1016/j.jcin.2009.12.008

Objectives We sought to compare outcomes in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) with or without previous coronary artery bypass grafts (CABG). Background Limited information exists regarding procedural success and clinical outcomes of STEMI patients with CABG undergoing primary PCI. Methods The APEX-AMI (Assessment of Pexelizumab in Acute Myocardial Infarction) trial was a randomized, placebo-controlled trial of pexelizumab in STEMI patients with planned primary PCI: 128 of 5,745 (2.2%) patients had prior CABG. Clinical/procedural characteristics, culprit vessel (infarct-related artery [IRA]), and 90-day clinical outcomes were compared. Results Patients with previous CABG were more frequently men, older, had a higher incidence of comorbidities and multivessel disease. In patients with versus without prior CABG, PCI was performed less frequently, that is, 78.9% versus 93.9%; of those with prior CABG receiving PCI, Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 was also restored less often, that is, 82.5% versus 91.6% (both p < 0.001). In prior CABG, there was a nearly even designation of the IRA as a bypass graft (n = 63) versus a native vessel (n = 55): IRA post-PCI TIMI flow grade 3 was achieved in 66.7% versus 88.0%, respectively (p = 0.043). Prior CABG patients had increased 90-day death and composite 90-day death/congestive heart failure/shock. Excess death remained significant after multivariable adjustment (hazard ratio: 1.9, 95% confidence interval: 1.08 to 3.33, p = 0.025). When prior CABG patients were stratified by the type of IRA, there was further discrimination of the increased 90-day death, that is, 19% bypass graft (n = 63) versus 5.7% native vessel (n = 55, p = 0.05), respectively. Conclusions Prior CABG patients with STEMI are less likely to undergo acute reperfusion, have worse angiographic outcomes following primary PCI, and higher 90-day mortality. These findings are especially applicable when the IRA was a bypass graft.