Prior Coronary Artery Bypass Graft Surgery Research Articles

Comparison of Outcomes of Percutaneous Coronary Intervention on Native Coronary Arteries Versus on Saphenous Venous Aorta Coronary Conduits in Patients With Low Left Ventricular Ejection Fraction and Impella Device Implantation Achieved or Attempted (from the PROTECT II Randomized Trial and the cVAD Registry)

Patients with prior coronary artery bypass grafting (CABG) represent a high-risk cohort given associated medical conditions and worse outcome of saphenous vein graft compared with native vessel percutaneous coronary intervention (PCI). The goal of the current analysis was to compare clinical outcomes in 591 patients with and without prior CABG and multivessel coronary artery disease or unprotected left main disease and severely reduced left ventricular systolic function underwent Impella supported PCI from the PROTECT II randomized trial and the cVAD Registry. Patients with prior CABG surgery (n = 201) were compared with those without prior CABG surgery (n = 390). The primary end point of this analysis was overall mortality at 30 days. Patients with prior CABG surgery had greater Society of Thoracic Surgery mortality score compared with patients without prior CABG surgery, 7.6 ± 6.4 versus 5.1 ± 5.5, respectively, p <0.001. Saphenous vein graft PCI was performed in 17% of patients with prior CABG surgery. Number of vessels treated was lower in patients with prior CABG surgery compared with patients without prior CABG surgery, 1.66 ± 0.56 versus 1.89 ± 0.64, respectively, p <0.001. Achievement of TIMI 3 flow post PCI and overall PCI success was similar in the two groups. Overall mortality at 30 days was similar in patients with prior CABG surgery compared with patients without prior CABG surgery, 6.75% versus 6.61%, respectively, p = 1.0. In conclusion, in this high-risk cohort of patients underwent hemodynamically supported PCI, prior CABG surgery was not associated with worse outcome. The use of hemodynamic support appears to mitigate the increased risk of PCI associated with prior CABG.

The benefit of adding ezetimibe to statin therapy in patients with prior coronary artery bypass graft surgery and acute coronary syndrome in the IMPROVE-IT trial.

To examine the efficacy and safety of ezetimibe added to statin in patients with prior coronary artery bypass graft surgery (CABG) following hospitalization for an acute coronary syndrome (ACS). In the IMPROVE-IT trial, post-ACS patients with mean low density lipoprotein cholesterol (LDL-C) of 93.8 mg/dL at presentation were randomized to simvastatin/ezetimibe or simvastatin/placebo. The primary endpoint was cardiovascular death, major coronary event or stroke, and the median follow-up was 6 years. Efficacy and safety endpoints were examined by prior CABG status. Among 18 134 patients, 1684 (9.3%) had a prior CABG (median age 69 years, 82% male). During the trial, the median time-weighted LDL-C level was 55.0 mg/dL with simvastatin/ezetimibe vs. 69.9 mg/dL with simvastatin/placebo in patients with prior CABG (P < 0.001), and it was 53.6 mg/dL vs. 69.5 mg/dL, respectively, in patients without prior CABG (P < 0.001). The rate of the primary endpoint was higher in patients with vs. without prior CABG [56% vs. 32%, adj. hazard ratio 1.45, 95% confidence interval (CI) 1.33-1.58]. Patients with prior CABG receiving simvastatin/ezetimibe had an 8.8% (95% CI 3.1-14.6%) lower absolute risk over simvastatin/placebo in the primary endpoint, whereas patients without prior CABG had a 1.3% (95% CI 0-2.6%) lower absolute risk (P-interaction = 0.02). There were no between-group significant differences in safety endpoints. The clinical benefit of adding ezetimibe to statin appears to be enhanced in patients with prior CABG, supporting the use of intensive lipid lowering therapy in these high-risk patients following ACS.

Predictors and outcomes of early coronary angiography in patients with prior coronary artery bypass surgery presenting with non-ST elevation myocardial infarction

IntroductionThe best strategy in patients with prior coronary artery bypass graft surgery (CABG) who present with non-ST elevation myocardial infarction (NSTEMI) remains less well defined. We compare the characteristics, therapeutic...

DOES PRIOR CORONARY ARTERY BYPASS GRAFTING SURGERY IMPACT OUTCOME IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT?

Re-operation for aortic valve replacement after prior coronary artery bypass grafting surgery (CABG) is associated with increased risk for poor outcome. With transcatheter aortic valve replacement (TAVR) as an alternative for aortic valve surgery, it is not clear if prior CABG is also associated

Prevalence and management of coronary chronic total occlusions in a tertiary veterans affairs hospital

We sought to determine the contemporary prevalence and management of coronary chronic total occlusions (CTO) in a veteran population. The prevalence and management of CTOs in various populations has received limited study. We collected clinical and angiographic data in consecutive patients that underwent coronary angiography at our institution between January 2011 and December 2012. Coronary artery disease (CAD) was defined as ≥50% diameter stenosis in ≥1 coronary artery. CTO was defined as total coronary artery occlusion of ≥3 month duration. Among 1,699 patients who underwent angiography during the study period, 20% did not have CAD, 20% had CAD and prior coronary artery bypass graft surgery (CABG), and 60% had CAD but no prior CABG. The prevalence of CTO among CAD patients with and without prior CABG was 89 and 31%, respectively. Compared to patients without CTO, CTO patients had more co-morbidities, more extensive CAD and were more frequently referred for CABG. Percutaneous coronary intervention (PCI) to any vessel was performed with similar frequency in patients with and without CTO (50% vs. 53%). CTO PCI was performed in 30% of patients without and 15% of patients with prior CABG with high technical (82 and 75%, respectively) and procedural success rates (80 and 73%, respectively). In a contemporary veteran population, coronary CTOs are highly prevalent and are associated with more extensive co-morbidities and higher likelihood for CABG referral. PCI was equally likely to be performed in patients with and without CTO.

Effect of ticagrelor on the outcomes of patients with prior coronary artery bypass graft surgery: Insights from the PLATelet inhibition and patient outcomes (PLATO) trial

Patients with prior coronary artery bypass graft surgery (CABG) who present with an acute coronary syndrome have a high risk for recurrent events. Whether intensive antiplatelet therapy with ticagrelor might be beneficial compared with clopidogrel is unknown. In this substudy of the PLATO trial, we studied the effects of randomized treatment dependent on history of CABG. Patients participating in PLATO were classified according to whether they had undergone prior CABG. The trial's primary and secondary end points were compared using Cox proportional hazards regression. Of the 18,613 study patients, 1,133 (6.1%) had prior CABG. Prior-CABG patients had more high-risk characteristics at study entry and a 2-fold increase in clinical events during follow-up, but less major bleeding. The primary end point (composite of cardiovascular death, myocardial infarction, and stroke) was reduced to a similar extent by ticagrelor among patients with (19.6% vs 21.4%; adjusted hazard ratio [HR], 0.91 [0.67, 1.24]) and without (9.2% vs 11.0%; adjusted HR, 0.86 [0.77, 0.96]; P(interaction) = .73) prior CABG. Major bleeding was similar with ticagrelor versus clopidogrel among patients with (8.1% vs 8.7%; adjusted HR, 0.89 [0.55, 1.47]) and without (11.8% vs 11.4%; HR, 1.08 [0.98, 1.20]; P(interaction) = .46) prior CABG. Prior-CABG patients presenting with acute coronary syndrome are a high-risk cohort for death and recurrent cardiovascular events but have a lower risk for major bleeding. Similar to the results in no-prior-CABG patients, ticagrelor was associated with a reduction in ischemic events without an increase in major bleeding.

Paradoxical septal motion from prior coronary artery bypass graft surgery does not impact left ventricular mechanical dyssynchrony by gated myocardial perfusion imaging

BackgroundPhase analysis of gated myocardial perfusion imaging (MPI) provides automated and reproducible assessment of left ventricular (LV) mechanical dyssynchrony (LVMD) (phase standard deviation [SD]). Many patients undergoing gated MPI have history of prior coronary artery bypass graft surgery (CABG). The latter is often associated with paradoxical septal wall motion (PSM). The effect of prior CABG and PSM on LVMD has not been evaluated. Methods and ResultsFrom the single-photon emission computed tomography (SPECT) and positron emission tomography (PET) MPI clinical database maintained at the Cleveland Clinic, we identified 200 consecutive patients with SPECT (100 control with normal LV ejection fraction [EF], MPI, and QRS < 120 ms; and 100 with LVEF < 35%), and 631 patients with LVEF < 35% with gated PET. Patients with QRS ≥ 120 ms, bundle branch block, ventricular pacing or isolated non-CABG surgery were excluded. There were 162 patients with gated SPECT (46 with prior CABG), and 568 with gated PET (220 with prior CABG) that were left for analysis. Phase SD was derived using Emory Cardiac Toolbox (ECTb) (for gated SPECT) and Corridor 4DM (4DM) (for gated SPECT and PET images). Multivariate linear regression analysis was performed to assess whether prior CABG was an independent predictor of worse LV mechanical dyssynchrony. After adjusting for patients’ demographics, co-morbidities, medications, and MPI data, history of prior CABG was not and independent predictor of LV mechanical dyssynchrony (P = .67 with 4DM, P = .97 with ECTb) in patients undergoing gated SPECT or among patients undergoing gated PET imaging (P = .18). ConclusionsAlthough paradoxical septal wall motion is commonly seen after cardiac surgery, prior CABG does not affect or impact LV mechanical dyssynchrony indices measured from gated SPECT or PET images. Whether dyssynchrony measurements with echocardiography that has higher temporal resolution might uncover intraventricular delays, remains to be determined.

Abstract 19050: Does Type of Culprit Lesion Matter in Patients with Acute Coronary Syndrome and Prior Coronary Artery Bypass Graft Surgery Undergoing Percutaneous Coronary Intervention?

Background: Acute coronary syndrome (ACS) in patients with prior coronary artery bypass graft (CABG) surgery may be due to graft failure or progression of native coronary artery disease. We studied whether the culprit lesion (graft vs. native) is associated with differences in hospital and long-term outcomes. Methods: We included ACS patients with prior CABG who underwent percutaneous coronary intervention (PCI) of &gt;=1 lesion at the Academic Medical Center - University of Amsterdam between 1998 and 2008. The primary outcome was 5-year mortality and the secondary outcome was a composite of in-hospital death, myocardial infarction, need-for-revascularization and stroke. Kaplan-Meier estimates were used to compare 5-year mortality between patients with graft vs. native culprit lesions. Predictors for 5-year mortality were identified using multivariable Cox proportional hazards modeling with backwards variable selection. Logistic regression was used to assess predictors for in-hospital outcomes. Results: Overall, 270 patients were included, of which 146 (54.1%) had a graft culprit lesion. Mean age was 70 (SD=9.5yrs), 21.9% were women. Multi-vessel PCI was performed in 50 (18.5%) patients. 5-year mortality was similar following graft versus native culprit lesion PCI (41.3% vs. 36.4%, HR:1.16, 95%-CI:0.73-1.84, p=0.52). In-hospital death, MI, need-for-revascularization and/or stroke was also comparable (16.4% vs. 13.7%, HR:1.24 (95%-CI:0.63-2.43), p=0.53). Similar results were seen after adjusting for important covariates. Older age, lack of prior aspirin use, and cardiogenic shock were independently associated with worse clinical outcomes. Conclusion: Type of culprit lesion (either native or graft) in patients presenting with ACS and prior CABG surgery was not associated with in-hospital or long-term clinical outcomes. Larger studies to validate our findings are warranted.

Acute Coronary Syndrome in Patients with Prior Coronary Artery Bypass Surgery: Observations from a 20-Year Registry in a Middle-Eastern Country

ObjectivesClinical characteristics and trends in the outcome of acute coronary syndrome (ACS) in patients with prior coronary artery bypass graft surgery (CABG) are unclear. The aim of this study was to evaluate clinical characteristics, in-hospital treatment, and outcomes in patients presented with ACS with or without a history of prior CABG over 2 decades.MethodsData were derived from hospital-based study for collected data from 1991 through 2010 of patients hospitalized with ACS in Doha, Qatar. Data were analyzed according to their history of prior CABG. Baseline clinical characteristics, in-hospital treatment, and outcome were compared.ResultsA total 16,750 consecutive patients with ACS were studied, of which 693 (4.1%) had prior CABG. Patients with prior CABG were older (mean 60.5±11 vs. 53±12 years; P = 0.001), more likely to be females and have more cardiovascular risk factors than the non-CABG group. Prior CABG patients had larger infarct size, were less likely to receive reperfusion therapy, early invasive therapy and more likely to receive evidence-based therapies when compared to non-CABG patients. In-hospital mortality and stroke rates were comparable between the 2 groups. Over 2 decades, there was reduction in the in-hospital mortality rates and stroke rates in both groups (CABG, death; 13.2% to 4%, stroke; 1.9% to 0.0%, non-CABG, death; 10% to 3.2%, stroke 1.0% to 0.1%; all, p = 0.001).ConclusionSignificant reduction in-hospital morbidity and mortality among ACS patients with prior CABG over a 20-year period.

Abstract P133: Effect of Prior Cardiac Surgery on Survival After CABG Surgery

Background: We examined a recent regional experience to determine the impact of a prior cardiac surgery on short and long-term outcomes following coronary artery bypass grafting (CABG) surgery. Methods: We identified 20,504 patients undergoing non-emergent CABG surgery at 8 centers in northern New England from 2000-2008, of whom 818 (4.0%) had undergone prior cardiac surgery. Prior CABG and/or valve surgery utilizing a mini- or full sternotomy was considered a prior sternotomy. Survival data was obtained by linkage to the Social Security Administration Death Index. Hazard ratios were estimated using a Cox Proportional Hazards regression model while adjusted survival curves were estimated using inverse probability weighting. Models were adjusted for age, sex, ejection fraction, acuity, vascular disease, diabetes, prior myocardial infarction, renal failure or creatinine &gt;2 mg/dl, left main disease, chronic obstructive pulmonary disease, body mass index, medical center and year. We conducted a nearest-neighbor propensity matched analysis among a subset of 1,568 patients who were matched 1:1 having a prior cardiac procedure based on their history of a cardiac surgical procedure and aforementioned patient and disease characteristics. Results: In both instances, prior sternotomy was associated with increased risk of mortality for patients undergoing CABG: [adjusted unmatched HR: 1.68, (CI 95% 1.46, 1.93)]; [propensity matched HR: 1.44, (CI 95% 1.12, 1.86)]. Conclusions In our recent regional experience with non-emergent CABG, a prior cardiac surgery was associated with a nearly two-fold increased hazard of mortality at up to 4 years of follow-up.

Characteristics, management and outcomes of patients with acute coronary syndrome and prior coronary artery bypass surgery: findings from the second Gulf Registry of Acute Coronary Events

To evaluate the baseline demographic/clinical characteristics, in-hospital treatment and outcomes among patients with or without prior coronary artery bypass graft surgery (CABG) presenting as acute coronary syndrome (ACS) from six Middle East countries. Data was derived from a prospective, multinational, multicenter registry of 7881 consecutive patients hospitalized with ACS in six Middle East countries. Data were analyzed according to their history of prior CABG. Of 7881 ACS patients, 336 (4.2%) had a history of CABG. Patients with prior CABG were older (mean 63 ± 10.8 vs. 56 ± 12.6 years; P = 0.001) and more frequently to be men (76%) with significantly more prior angina, infarction and percutaneous revascularization. They were more likely to have hypertension, diabetes, hyperlipidemia, prior congestive heart failure, stroke, renal failure, peripheral arterial disease and had higher prevalence of previous treatment with evidence-based medications. They were more likely to present with unstable angina (45.5% vs. 23.4%), followed by non-ST elevation myocardial infarction (STEMI) (43.8% vs. 29.5%), STEMI (10.7% vs. 47.1%) (All P = 0.001) with less prominent peak values of cardiac biomarkers than patients without prior CABG. Patients with prior CABG were more likely to present with significantly worse Killip class (≥ 2), higher Global Registry of Acute Coronary Events (GRACE) risk score, multivessel disease, severe left ventricular (LV) dysfunction (LV ejection fraction ≤ 30%) and developed significantly higher cardiogenic shock and major bleeding. In patients with prior CABG, no significant difference was observed in in-hospital mortality (4.2% vs. 4.6%, P=0.735) or mortality at one month (6.5% vs. 8.2%, P=0.277) or after one year (15% vs. 12.4%, P=0.204) when compared to patients without prior CABG. ACS patients from Middle East countries with prior CABG have adverse baseline characteristics, reported higher GRACE risk score, multivessel disease, more severe LV dysfunction, cardiogenic shock, in-hospital major bleeding, but with less incidence of STEMI with less prominent surge of cardiac biomarkers. However, there was no significant difference in mortality during hospitalization, at 30 days and at one year between ACS patients with and without prior CABG. The reasons for this 'risk-mortality' paradox need to be further evaluated.

Percutaneous Coronary Intervention in Native Arteries Versus Bypass Grafts in Prior Coronary Artery Bypass Grafting Patients: A Report From the National Cardiovascular Data Registry

This study examined a large registry to determine the frequency, predictors, and outcomes of native coronary artery versus bypass graft percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass graft surgery (CABG). The PCI target vessel and corresponding outcomes in prior CABG patients are poorly studied. We analyzed the frequency and factors associated with native versus bypass graft PCI in prior CABG patients undergoing PCI between January 1, 2004, and June 30, 2009, in the National Cardiovascular Data Registry (NCDR) CathPCI Registry. Generalized estimating equations logistic regression modeling was used to generate independent variables associated with native versus bypass graft PCI and in-hospital mortality. During the study period, PCI in prior CABG patients represented 17.5% of the total PCI volume (300,902 of 1,721,046). The PCI target was a native coronary artery in 62.5% and a bypass graft in 37.5%: saphenous vein graft (SVG) (104,678 [34.9%]), arterial graft (7,517 [2.5%]), or both arterial graft and SVG (718 [0.2%]). Compared with patients undergoing native coronary artery PCI, those undergoing bypass graft PCI had higher-risk characteristics and more procedural complications. On multivariable analysis, several parameters (including graft stenosis and longer interval from CABG) were associated with performing native coronary PCI, and bypass graft PCI was associated with higher in-hospital mortality (adjusted odds ratio: 1.22, 95% confidence interval: 1.12 to 1.32). Most PCIs performed in prior CABG patients are done in native coronary artery lesions. Compared with native coronary PCI, bypass graft PCI is independently associated with higher in-hospital mortality.

Prevalence, Predictors, and Outcomes of Conservative Medical Management in Non-ST-Segment Elevation Acute Coronary Syndromes in Gulf RACE-2

We assessed the prevalence, predictors, and in-hospital and long-term outcomes of conservative medical management for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) compared with percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG). This prospective study conducted from October 2008 to June 2009 in 65 hospitals from 6 Arabian Gulf countries included 30-day and 1-year mortality follow-up for 3661 patients. Compared with conservative management group (2859 patients; 78.1%), the PCI group (638; 17.4%) had significantly better unadjusted and adjusted in-hospital (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.17-0.97), 30-day (OR: 0.44, 95% CI: 0.24-0.76) and 1-year (OR: 0.58, 95% CI: 0.40-0.87) mortality rates. Comparison with the CABG group (164; 4.5%) yielded similar results with inclusion of patients scheduled for CABG after hospital discharge. Independent predictors of conservative medical management were mainly country of residence and history of prior CABG.

Association of prior coronary artery bypass graft surgery with quality of care of patients with non–ST-segment elevation myocardial infarction: A report from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines

The American College of Cardiology/American Health Association guidelines recommend both an early invasive strategy and administration of antiplatelet/anticoagulant therapy for high-risk patients in the absence of contraindications. Little is known about adherence to guideline recommendations in patients with prior coronary artery bypass graft (CABG) surgery presenting with non-ST-segment elevation myocardial infarction (NSTEMI). We analyzed 47,557 patients with NSTEMI in the 2007-2008 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines. Treatment patterns were compared between patients with and without prior CABG surgery. Multivariable regression with generalized estimating equations evaluated the association between prior CABG and in-hospital outcomes. In this study, 8,790 NSTEMI patients (18.5%) had a history of CABG surgery. Prior CABG surgery was associated with a significantly lower adjusted likelihood of early cardiac catheterization (adjusted odds ratio [OR] 0.88, 95% CI 0.83-0.92), higher rates of short-term clopidogrel use (adjusted OR 1.08, 95% CI 1.02-1.14), and comparable use of anticoagulant therapy (adjusted OR 0.96, 95% CI 0.88-1.04). Adjusted risks of bleeding and in-hospital mortality did not differ significantly between the 2 groups (adjusted ORs 1.00, 95% CI 0.92-1.11 and 0.99, 95% CI 0.87-1.11, respectively). Patients with prior CABG surgery presenting with NSTEMI are often felt to be at high risk for adverse outcomes and therefore require aggressive treatment. Our study indicates that they are less likely to undergo guideline-recommended early cardiac catheterization but equally or more likely to receive guideline-recommended antiplatelet and anticoagulant therapy. This risk-treatment paradox, however, does not appear to negatively influence short-term clinical outcomes.

Giant Saphenous Vein Graft Aneurysm Causing Left Atrial Compression and Cardiogenic Shock

Saphenous vein graft aneurysm is a rare complication of coronary artery bypass graft (CABG) surgery that is challenging to manage and is associated with catastrophic consequences. We present the case of a 72-year-old woman with prior CABG surgery who presented with chest pain and was found to have a giant saphenous vein graft pseudoaneurysm. Further evaluation revealed that a vein graft pseudoaneurysm was causing significant compression of the left atrium. The pseudoaneurysm was successfully excluded from the blood flow with a covered stent; however, despite intra-aortic balloon pump and supportive therapy, the patient succumbed to cardiogenic shock and sepsis.

Management patterns of non-ST segment elevation acute coronary syndromes in relation to prior coronary revascularization

Contemporary guidelines support an early invasive strategy for non-ST elevation acute coronary syndrome (NSTE-ACS) patients who had prior coronary revascularization. However, little is known about the management pattern of these patients in "real world." We analyzed 3 consecutive Canadian registries (ACS I, ACS II, and Global Registry of Acute Coronary Events [GRACE]/expanded-GRACE) that recruited 12,483 NSTE-ACS patients from June 1999 to December 2007. We stratified the study population according to prior coronary revascularization status into 4 groups and compared their clinical characteristics, in-hospital use of medications, and cardiac procedures. Of the 12,483 NSTE-ACS patients, 71.2% had no prior revascularization, 14.2% had percutaneous coronary intervention (PCI) only, 9.5% had coronary artery bypass graft surgery (CABG) only, and 5% had both PCI and CABG. Compared to their counterparts without prior revascularization, patients with previous PCI and/or CABG were more likely to be male, to have diabetes, myocardial infarction, and heart failure but less likely to have ST-segment deviation or positive cardiac biomarker on presentation. Early use of evidence-based medications was higher among patients with previous PCI only and lower among patients with previous CABG only. After adjusting for possible confounders including GRACE risk score, prior PCI was independently associated with in-hospital use of cardiac catheterization (adjusted odds ratio [OR] 1.18, 95% CI 1.04-1.34, P = .008). In contrast, previous CABG was an independent negative predictor (adjusted OR .77, 95% CI 0.68-0.87, P < .001). There was no significant interaction (P = .93) between previous PCI and CABG. The NSTE-ACS patients with previous PCI were more likely to be treated invasively. Conversely, patients with prior CABG less frequently received invasive therapy. Future studies should determine the appropriateness of this treatment discrepancy.

Prior coronary artery bypass graft surgery patients undergoing diagnostic coronary angiography have multiple uncontrolled coronary artery disease risk factors and high risk for cardiovascular events

Limited contemporary data exist on the cardiovascular risk of patients with prior coronary artery bypass grafting surgery (CABG) requiring diagnostic coronary angiography. We examined the prevalence and control of coronary artery disease risk factors and the outcomes of 367 prior CABG patients who underwent diagnostic coronary angiography between October 1, 2004 and May 31, 2007 at the Dallas Veterans Affairs Medical Center. Mean age was 65 +/- 9 years, 97% were men, and the mean time from CABG to diagnostic angiography was 8.2 +/- 6.1 years. Hypertension, low-density lipoprotein cholesterol, diabetes mellitus, smoking, and obesity were suboptimally controlled in 70%, 59%, 47%, 33%, and 50%, respectively. Intake of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers was 88% and 81%, respectively. After a mean follow-up of 1.4 +/- 0.8 years, the incidence of death and major cardiovascular events was 10% and 32%, respectively. In spite of significant improvement compared to previous studies and good compliance with indicated medications, contemporary prior CABG patients undergoing coronary angiography still have multiple and poorly controlled coronary artery disease risk factors and high risk for cardiovascular events. Novel pharmacologic and behavioral treatment strategies are needed.

Comparison of percutaneous coronary intervention in native coronary arteries vs. bypass grafts in patients with prior coronary artery bypass graft surgery

To compare the procedural and clinical outcomes of prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) in native arteries vs. bypass grafts. The medical and catheterization records and the angiograms of 142 consecutive prior CABG patients who underwent 165 PCI of 247 lesions at our institution between January 1, 2003, and December 31, 2006, were retrospectively reviewed. Mean age was 66+/-10 years and 99% were men: 79 and 63 patients underwent native coronary or bypass graft PCI, respectively. Compared to patients undergoing bypass graft PCI, those undergoing native coronary artery PCI were younger (mean age 64+/-10 vs. 68+/-10 years, P=.008), more likely to present with stable angina (29% vs. 8%, P=<.001), and presented earlier after CABG (after a mean of 9+/-6 vs. 12+/-5 years, P<.01). Compared to bypass graft PCI, native coronary PCI was more likely to be performed with drug-eluting stents (88% vs. 57%, P<.001) and was associated with lower risk of no-reflow (3% vs. 24%, P<.001). After a mean follow-up of 2.5+/-1.1 years, both groups of patients had similar but high incidence of myocardial infarction, repeat PCI, and death. Prior CABG patients undergoing native coronary artery PCI have lower procedural risk, but similar postprocedural clinical outcomes compared to patients undergoing bypass graft PCI. If feasible, native coronary arteries may be the preferred PCI target in prior CABG patients.

Abstract 1515: Outcomes of Patients With Acute Coronary Syndromes and Prior Coronary Artery Bypass Grafting. Results From the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT-TIMI 22) and the Aggrastat to Zocor (A to Z) trials.

Background: Patients with prior coronary artery bypass graft surgery (CABG) who develop acute coronary syndromes (ACS) are at high risk for major adverse cardiac events. The benefits of intensive statin therapy, targeting an LDL cholesterol of &lt; 70 mg/dL, in patients with ACS and prior CABG have not been well studied. Methods: The effect of intensive vs. moderate statin therapy was assessed in patients with and without prior CABG participating in the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT TIMI 22) or the Aggrastat to Zocor (A to Z) trials. Results: Six hundred and forty of the 8655 patients (7.4%) enrolled in PROVE IT-TIMI 22 or A to Z had undergone CABG prior to enrollment. Prior CABG patients were older, more likely to be men and had a higher TIMI risk score. After a median follow-up of 2 years, compared to patients without prior CABG, those with prior CABG had higher risk of cardiovascular death (6.2 vs. 2.8%), myocardial infarction (14.2% vs. 6.6%), and readmission for ACS (7.9% vs. 4.4%) (p&lt;0.001 for all comparisons), but a lower rate of repeat coronary revascularization (22.7% vs. 26.9%, p=0.01). Compared to moderate statin therapy, intensive statin therapy decreased the combined endpoint of cardiovascular death, myocardial infarction, stoke, and readmission for an acute coronary syndrome (A to Z primary endpoint) to a similar extent in patients with and without prior CABG (Table ). The benefit of intensive statin therapy in prior CABG patients appeared to be due to a reduction in unstable angina requiring hospitalization, with no significant difference in the incidence of death, myocardial infarction, or coronary revascularization. Conclusions: Compared to ACS patients without prior CABG, those with prior CABG have significantly higher risk for death and adverse cardiac events and appear to show similar benefit from intensive statin therapy. Effect of intensive statin therapy on outcomes of patients with and without prior CABG

Early Invasive Strategy Improves Outcomes in Patients With Acute Coronary Syndrome With Previous Coronary Artery Bypass Graft Surgery

Patients with previous coronary artery bypass graft surgery (CABG) have been classified as a high-risk subset of patients who experience non-ST elevation acute coronary syndrome (ACS). Recent studies suggest that an early invasive strategy is beneficial in moderate- and high-risk patients with non-ST elevation ACS. We hypothesized that an early invasive strategy is associated with improved outcomes in patients with non-ST elevation ACS with prior CABG. In the Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction 18 trial (TACTICS-TIMI 18), 2220 patients with non-ST segment elevation ACS were randomized to an early invasive or conservative (selectively invasive) strategy. All patients were treated with aspirin, heparin, and tirofiban. Four hundred eighty-four (22%) of these patients had undergone CABG before enrollment. We analyzed whether patients with previous CABG had different 6-month outcomes and whether an early invasive strategy was associated with an improvement in long-term outcomes. Prior CABG was associated with a higher risk of adverse outcomes by 6 months, including a higher rate of readmission for ACS (17.4% vs 11.0%, P < 0.001) and a higher incidence of the composite end point of death, myocardial infarction, or rehospitalization for ACS (22.3% vs 16.4%, P = 0.002). There was a trend toward a higher incidence of myocardial infarction (7.1% vs 5.3%, P = 0.051). An early invasive strategy was associated with a reduction in the composite of death or myocardial infarction (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.31-1.0; P = 0.089) and a significant reduction in the incidence of myocardial infarction at 6 months (OR, 0.44; 95% CI, 0.21-0.93; P=0.032). Patients with non-ST segment elevation ACS who have had previous CABG are a high-risk subset. An early invasive strategy reduces risk of myocardial infarction in this high-risk group.