Timing of In-Hospital Coronary Artery Bypass Graft Surgery for Non–ST-Segment Elevation Myocardial Infarction Patients: Results From the National Cardiovascular Data Registry ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines)

Abstract

The aim of this study was to examine timing of in-hospital coronary artery bypass graft surgery (CABG) for non-ST-segment elevation myocardial infarction (NSTEMI) patients. Although practice guidelines recommend delaying CABG for a few days after presentation for ST-segment elevation myocardial infarction patients, current guidelines for NSTEMI patients do not address optimal CABG timing. We evaluated rates and timing of in-hospital CABG among NSTEMI patients treated at U.S. hospitals from 2002 to 2008 with the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) (January 2002 to December 2006) and ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines) (January 2007 to June 2008) programs. Analyses designed to study the clinical characteristics and outcomes of early (<or=48 h, n = 825) versus late (>48 h, n = 1,822) CABG focused upon more recent NSTEMI patients from the ACTION Registry-GWTG. Both the rate (11% to 13%) and timing (30% early and 70% late) of in-hospital CABG remained consistent from 2002 to 2008. In the ACTION Registry-GWTG program, NSTEMI patients undergoing late CABG tended to have a higher risk profile than those undergoing early CABG. In-hospital mortality (3.6% vs. 3.8%, adjusted odds ratio: 1.12, 95% confidence interval: 0.71 to 1.78) and the composite outcome of death, myocardial infarction, congestive heart failure, or cardiogenic shock (12.6% vs. 12.4%, adjusted odds ratio: 0.94, 95% confidence interval: 0.69 to 1.28) were similar between patients undergoing early versus late CABG. Most NSTEMI patients undergo late CABG after hospital arrival. Although these patients have higher-risk clinical characteristics, they have the same risk of adverse clinical outcomes compared with patients who undergo early CABG. Thus, delaying CABG routinely after NSTEMI might increase resource use without improving outcomes. Additionally, the timing of CABG for NSTEMI patients might be appropriately determined by clinicians to minimize the risk of adverse clinical events.