Timing of Coronary Artery Bypass Surgery after ST-Elevation Myocardial Infarction

Leontyev S. A., Davierwala P. M., Verevkin A. , Mohr F. W.

Heart Center Leipzig;

Objective:
We aimed to determine the effect of time-interval between onset of ST-elevation myocardial infarction (STEMI) and coronary artery bypass grafting (CABG) on 30-day mortality and long-term outcomes.

Methods:
Between January 2007 and December 2012, 231 patients underwent CABG within 21 days after STEMI at our institution. Forty patients were in cardiogenic shock (CS). Patients were divided into three groups according to the time-interval between onset of STEMI and CABG: Group A:<14 hours (n=43), Group B:14-72 hours (n=101), and Group C:>72 hours-21 days (n=87).

Results:
Overall 30-day mortality was 16%, decreasing to 9.9% after exclusion of CS patients. Group-wise 30-day mortality was 3%, 22.8%, and 11.5% (p=0.04) in groups A, B, and C, respectively, and fell to 0%, 14.5%, and 9.8% (p=0.07) after exclusion of CS patients. Operative timing did not predict 30-day mortality, even after exclusion of CS patients. Five-year survival was 70±9%, 53±6% and 65±7% for groups A, B, and C [log rank:p=0.03], respectively. Group B was found to be an independent predictor of long-term mortality in all patients (OR:1.8; 95%CI:1.1-2.9;p=0.02). After excluding patients with CS, CABG performed within 14 hours of STEMI (Group A) was protective against long-term mortality (OR:0.2;95%CI:0.1-0.7;p=0.009).

Conclusions
CABG performed within the first 14 hours after STEMI is associated with good early and long-term survival. Hence, when indicated, surgery should be performed as early as possible in such patients. If delay is inevitable, surgery should be deferred for at least 72 hours post-STEMI in patients without indications for emergency revascularisation.

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