CLINICAL STUDIES
Clinical and angiographic outcomes in patients with previous coronary artery bypass graft surgery treated with primary balloon angioplasty for acute myocardial infarction
Gregg W. Stone, MD, FACC*,
Bruce R. Brodie, MD, FACC ,
John J. Griffin, MD, FACC ,
Lorelei Grines, PhD ,
Judith Boura, MS,
William W. O’Neill, MD, FACC,
Cindy L. Grines, MD, FACC for the Second Primary Angioplasty in Myocardial Infarction Trial (PAMI-2) Investigators1
* Cardiovascular Research Foundation, Washington Hospital Center, Washington, DC, USA
Division of Cardiology, Moses Cone Hospital, Greensboro, North Carolina, USA
Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan, USA
Division of Cardiology, Virginia Beach General Hospital, Virginia Beach, Virginia, USA
Manuscript received December 31, 1998;
revised manuscript received October 15, 1999,
accepted November 18, 1999.
Reprint requests and correspondence: Dr. Gregg W. Stone, The Cardiovascular Research Foundation, 55 E. 59th Street, 6th floor, New York, New York 10022
OBJECTIVES
We sought to characterize the presenting characteristics of patients with previous coronary artery bypass graft surgery (CABG) and acute myocardial infarction (AMI) and to determine the angiographic success rate and clinical outcomes of a primary percutaneous transluminal coronary angioplasty (PTCA) strategy.
BACKGROUND
Patients who have had previous CABG and AMI comprise a high risk group with decreased reperfusion success and increased mortality after thrombolytic therapy. Little is known about the efficacy of primary PTCA in AMI.
METHODS
Early cardiac catheterization was performed in 1,100 patients within 12 h of onset of AMI at 34 centers in the prospective, controlled Second Primary Angioplasty in Myocardial Infarction trial (PAMI-2), followed by primary PTCA when appropriate. Data were collected by independent study monitors, end points were adjudicated and films were read at an independent core laboratory.
RESULTS
Of 1,100 patients with AMI, 58 (5.3%) had undergone previous CABG. The infarct-related vessel in these patients was a bypass graft in 32 patients (55%) and a native coronary artery in 26 patients. Compared with patients without previous CABG, patients with previous CABG were older and more frequently had a previous myocardial infarction and triple-vessel disease. Coronary angioplasty was less likely to be performed when the infarct-related vessel was a bypass graft rather than a native coronary artery (71.9% vs. 89.8%, p = 0.001); Thrombolysis in Myocardial Infarction trial (TIMI) flow grade 3 was less frequently achieved (70.2% vs. 94.3%, p < 0.0001); and in-hospital mortality was increased (9.4% vs. 2.6%, p = 0.02). As a result, mortality at six months was 14.3% versus 4.1% in patients with versus without previous CABG (p = 0.001). By multivariate analysis, independent determinants of late mortality in the entire study group were advanced age, triple-vessel disease, Killip class and post-PTCA TIMI flow grade <3.
CONCLUSIONS
Reperfusion success of a primary PTCA strategy in patients with previous CABG, although favorable with respect to historic control studies, is reduced as compared with that in patients without previous CABG. New approaches are required to treat patients with previous CABG and AMI, especially when the infarct-related vessel is a diseased saphenous vein graft.
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Abbreviations and Acronyms
| | AMI | = acute myocardial infarction | | CABG | = coronary artery bypass graft surgery | | CK-MB | = creatine kinase, MB fraction | | PAMI | = Primary Angioplasty in Myocardial Infarction trial | | PTCA | = percutaneous transluminal coronary angioplasty | | t-PA | = tissue-type plasminogen activator | | TIMI | = Thrombolysis in Myocardial Infarction trial | | TVR | = target vessel revascularization |
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