Primary percutaneous coronary interventions in patients with acute myocardial infarction and prior coronary artery bypass grafting

BACKGROUND: The outcome of patients with previous coronary artery bypass grafting (CABG) undergoing primary percutaneous coronary intervention (PCI) for the treatment of acute myocardial infarction (AMI) is unclear. We sought to assess the outcome of patients with prior CABG undergoing primary PCI for the treatment of AMI. METHODS AND RESULTS: Between 1991 and 1997, 1072 patients with AMI underwent primary PCI without antecedent thrombolytic therapy at the Mayo Clinic. There were 128 patients with previous CABG and 944 without previous CABG. Patients with previous CABG were further subdivided according to the treated vessel: native vessels (n = 65) and bypass graft (n = 63). Clinical and angiographic characteristics and 30-day and 1-year outcomes were evaluated. Patients with previous CABG were significantly older and had a higher incidence of diabetes, hypertension, and hypercholesterolemia. They had a lower left ventricular ejection fraction and were also more likely to have congestive heart failure. After 1 year of follow-up, adverse cardiac events (death, MI, CABG, or repeat PCI) were significantly greater in patients with prior CABG (49.2% vs 35.9%, P =.04). With use of multivariate logistic regression analysis to adjust for differences in baseline characteristics, the treatment of vein graft was independently associated with adverse cardiac events (relative risk 1.48 [95% confidence interval 1.07-2.03], P =.02), but a history of prior CABG itself was not (relative risk 1.22 [95% confidence interval 0.96-1.56], P =.11). CONCLUSIONS: Primary PCI for AMI in patients with previous CABG is associated with higher adverse events largely attributable to adverse baseline clinical characteristics and the treatment of a vein graft.     

Coronary angioplasty in patients with prior coronary artery bypass grafting

We studied the clinical and angiographic outcome of patients with prior coronary arterial bypass grafting who underwent percutaneous transluminal coronary angioplasty at the Royal Infirmary of Edinburgh. Over a 4 year period, 47 patients with prior bypass surgery underwent angioplasty of 23 stenotic graft sites and 37 stenotic sites of native vessels. The procedure was performed a mean of 31.3 months after surgery for recurrence of symptoms refractory to maximal medical treatment. Satisfactory angiographic results were achieved in 42 patients (58 stenotic grafts or native vessels). At a median follow up period of 18 months, 20 patients were symptomatically improved, but 22 patients experienced recurrence of symptoms a mean of 4.7 months after angioplasty, despite a good initial angiographic result. Overall, 4 patients had a repeat bypass grafting and 9 patients had a repeat angioplasty. Angioplasty can be used as an alternative to a repeat operation in patients with prior bypass grafting who experience recurrence of symptoms. Initial success rates are high and complication rates low. Restenosis or development of new lesions in the native circulation, and/or in the grafts, remain significant problems. Patients with a long asymptomatic interval (greater than 6 months) between the bypass operation and recurrence of symptoms are more likely to have better long-term results after successful angioplasty, perhaps because of slower progression of atherosclerotic heart disease.     

Mechanism of acute myocardial infarction in patients with prior coronary artery bypass grafting and therapeutic implications

Although acute myocardial infarction (AMI) is usually due to thrombotic occlusion when involving a native coronary artery, the mechanism responsible for AMI in patients with previous coronary artery bypass grafting (CABG) is not well understood. Since knowledge of pathophysiology of AMI may alter subsequent management, angiograms obtained between 1 hour and 7 days of AMI (median 1 day) were reviewed in 50 patients greater than 1 year after CABG. The culprit vessel was identified by the presence of residual stenosis and/or thrombus in the vessel supplying the infarct zone or by reviewing previous angiograms. The infarct vessel was identified as a vein graft in 38 (76%) patients, the native vessel in 8 patients (16%) and could not be accurately determined in 4 patients (8%). Among the 38 vein grafts suspected as the infarct vessel, unequivocal angiographic evidence of residual thrombus (filling defect/persistent staining) was present in 31 (82%) and was greater than 2 cm in length in 15 patients. Successful reperfusion occurred in only 2 of 8 (25%) grafts after intravenous thrombolytic therapy. Intragraft thrombolysis with or without additional angioplasty was successful at restoring flow in 8 of 10 (80%) grafts. Data indicate that in patients who have undergone previous CABG, AMI is usually caused by thrombotic occlusion of a saphenous vein graft and that conventional intravenous thrombolytic therapy may be inadequate to restore flow. The large mass of thrombus and absent flow in the graft may require subselective drug infusion, a higher thrombolytic dose or a mechanical means of recanalization.     

Usefulness of coronary artery angioplasty strategies in acute myocardial infarction

The usefulness of percutaneous transluminal coronary angioplasty (PTCA) as an adjunct to thrombolytic therapy for acute myocardial infarction is the focus of intense clinical investigation. With an angiographically significant residual stenosis present in the infarct vessel in at least 70% of cases, PTCA has the potential to resolve residual ischemia of surviving myocardium; provide a route for nutrient influx to promote healing and reorganization by leukocytes and fibroblasts; and maintain ventricular wall integrity. Additionally, the residual lesion may interfere with flow to collateral vessels supplying other diseased vascular territories, or inhibit the delivery of inotropic or antiarrhythmic agents to a problematic peri-infarct region. Various angioplasty strategies have been devised to define the optimal timing of PTCA in several clinical settings. Although the impact on resting left ventricular performance has been disappointing except in cases of cardiogenic shock, an approach involving early angiography with thoughtful triage to PTCA when feasible, has been associated with improved survival at one- to three-year follow-up, compared with a 'thrombolysis only' approach. The results of clinical trials investigating the role of PTCA as a direct method of revascularization; as a 'rescue' procedure following failed thrombolysis; as an empiric, immediate or deferred strategy; or as an elective adjunct to thrombolytic therapy only in the presence of subsequent ischemia are reviewed in detail.     

In-hospital outcome of primary PCI for patients with acute myocardial infarction and prior coronary artery bypass grafting

BackgroundThis study aims to analyze the in-hospital outcome of primary percutaneous coronary intervention (PCI) for patients with acute myocardial infarction (AMI) and prior coronary artery bypass grafting (CABG).MethodsThis was a retrospective study. From January 2011 to December 2018, the data of 78 consecutive patients (study group) with prior CABG, who received primary coronary angiography in the setting of ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI), were screened. The study group was compared with another well-matched 78 patients without a history of CABG (control group). The information of the coronary angiograms and clinical data of both groups were analyzed. Multivariate conditional logistic regression models were constructed to test the association between PCI success rate and the prior CABG at age ≥65 and <65 years, respectively.ResultsThe results revealed that the primary PCI success rate in the study group was significantly lower than in the control group (67.9% vs. 92.3%, P<0.001) and in-hospital mortality was significantly higher than in control group (11.5% vs. 2.5%, P=0.03). The multivariate logistic regression analysis indicated that the primary PCI success rate was significantly associated with the history of prior CABG both in young patients [age <65 years; odds ratio (OR) =5.26, 95% confidence interval (CI): 1.69–16.47] and elderly (age ≥65 years; OR =13.76, 95% CI: 2.72–69.75).ConclusionsThe patients who receive primary PCI with AMI and prior CABG have poor in-hospital outcomes, with low PCI success rates and high mortality.     

Inhospital outcome of acute myocardial infarction in patients with prior coronary artery bypass surgery

Objectives Our goals were to compare the characteristics of patients with and without prior coronary artery bypass graft (CABG) presenting with acute myocardial infarction (MI) with or without ST elevation/left bundle branch block (LBBB), and to evaluate the effect of ST shift on inhospital mortality. Methods and Results Using the National Registry of Myocardial Infarction-3 Registry, we identified 112,697 patients with acute MI without exclusion criteria. Of these, 15,936 (14.1%) had prior CABG. Patients with prior CABG had more adverse characteristics and were less likely to have ST elevation/LBBB than patients without prior CABG. The unadjusted mortality for ST elevation/LBBB patients was higher in patients with prior CABG versus without (16.2% vs 14.1%, P = .0001), whereas in patients without ST elevation/LBBB, prior CABG conferred a lower unadjusted mortality versus without (10.1% vs 12.4%, P = .0001). Adjusting for baseline differences, prior CABG was weakly associated with inhospital mortality in ST elevation/LBBB patients (odds ratio [OR], 1.11, 95% CI 1.00-1.23), but not in patients without ST elevation/LBBB (OR 0.99, 95% CI 0.92-1.07). Conclusion Acute MI patients with prior CABG are more likely to present without ST elevation/LBBB than patients without prior CABG. Prior CABG was weakly associated with inhospital mortality in patients with ST elevation/LBBB, but not in patients without these electrocardiographic findings. This suggests the differences in absolute mortality rates between patients presenting with MI with and without a history of prior CABG are largely caused by differences in baseline characteristics and presentation. (Am Heart J 2002;144:463-9.)     

Outcome of acute myocardial infarction in patients with prior coronary artery bypass grafting treated with combination reduced fibrinolytic therapy and abciximab

ST-segment elevation acute myocardial infarction (AMI) in patients who have undergone previous coronary artery bypass grafting (CABG) is associated with low reperfusion rates and poor outcome after fibrinolytic therapy. The efficacy of a combination strategy (reduced fibrinolytic plus platelet glycoprotein IIb/IIIa agent) in this setting is unknown. In the Global Use of Streptokinase and TPA for Occluded coronary arteries V (GUSTO V) trial, 553 patients with a history of CABG were treated with standard-dose reteplase (n = 273), or half-dose reteplase and full-dose abciximab (n = 280) in the first 6 hours of evolving ST-segment elevation MI. Mortality at 30 days was significantly higher in patients who underwent prior CABG compared with patients with no prior CABG (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.21 to 2.24, p = 0.001). In patients who underwent prior CABG, mortality at 7 days was reduced 15% with combination therapy compared with reteplase alone, which was not statistically significant (OR 0.85, 95% CI 0.40 to 1.81, p = 0.66). Patients who underwent prior CABG treated with the combination therapy had fewer episodes of recurrent ischemia (OR 0.60, 95% CI 0.37 to 0.96, p = 0.02), high degree atrioventricular block (OR 0.17, 95% CI 0.02 to 0.82, p = 0.01), and ventricular tachycardia (OR 0.29, 95% CI 0.07 to 0.96, p = 0.04). There was a trend toward reduced urgent revascularization (OR 0.61, 95% CI 0.36 to 1.03, p = 0.06) but no significant difference in reinfarction (OR 0.61, 95% CI 0.31 to 1.52, p = 0.40). In the GUSTO V trial, patients who underwent prior CABG had significantly higher event rates compared with patients without CABG. As in the overall trial, combination therapy in patients who underwent prior CABG led to a consistent reduction in key secondary complications of AMI, including recurrent ischemia and a trend toward reduced urgent revascularization.     

Outcome following emergency coronary artery bypass grafting for failed elective balloon coronary angioplasty in patients with prior coronary bypass

To assess frequency and outcome of emergency coronary artery bypass grafting (CABG) for failed coronary angioplasty in patients with prior CABG, 2,136 elective angioplasty procedures in prior CABG patients were reviewed over a 10-year period. Emergency surgical revascularization was required in 19 patients (0.9%) with prior CABG, compared with 130 of 6,974 patients (1.9%) without prior CABG (p = 0.001). The interval from the most recent CABG to the failed coronary angioplasty was 6.8 years (range 1 to 16). Referral for emergency CABG was made on the basis of an acute closure not responding to repeat dilatation in 12 native coronary arteries and in 7 saphenous vein grafts. Severe hemodynamic instability after acute closure required the placement of an intraaortic balloon pump in 3 patients, including 2 who required cardiopulmonary resuscitation. A total of 34 saphenous vein grafts and 1 internal mammary artery graft were placed emergently. Three patients with high-risk features (3 prior CABG operations in 1 patient, single remaining vessel to heart in 2 patients) could not be weaned from cardiopulmonary bypass. The remaining 16 patients were discharged after a mean hospital stay of 16 days. Four patients developed new Q waves after CABG. At follow-up (mean 52 months, range 3 to 99), 1 patient died late from an acute myocardial infarction. The 15 survivors had no or mild angina and were free of further CABG. Thus, emergency CABG after failed angioplasty in patients with prior CABG is required infrequently. In patients without extreme high-risk features, emergency repeat CABG can be accomplished with good hospital and long-term results.     

冠状动脉搭桥围术期急性心肌梗死紧急再搭桥

目的：回顾性分析冠状动脉搭桥围术期急性心肌梗死急诊再搭桥的临床经验。方法：在510例冠状动脉搭桥患中，5例患在术后4h内因急性心肌梗死需急诊再搭桥，发生率0．98％。5例患中，男女比例为4：1，年龄56－77岁（平均63．6岁），均为冠状动脉三支血管病变（3例伴左主干病变），手术中搭桥3－5支（人均搭桥3．6支），左乳内动脉桥5根，其余为大隐静脉桥。2例在关胸后20min，3例在回重症监护病房后2－4h出现急性心肌缺血表现（明显心电图ST－T变化），伴室颤2例，5例血液动力学均不稳定，药物处理难以稳定血液动力学。全部患均立即送手术室（2例仍在手术室），急诊再次开胸。探查发现，2例患静脉桥（分别搭桥到回旋支第二钝缘支和右冠状动脉后降支）内急性血栓形成；另3例所有静脉桥良好，但左室前壁收缩运动明显减弱，结合心电图变化，诊断为左乳内动脉灌注不良。重新建立体外循环，清除桥内血栓重新搭桥2例（1例在非体外循环心脏跳动下进行）；另取一段静脉搭桥到左乳内动脉－左前降支吻合口远端的左前降支3例。结果：5例患顺利度过手术，均置入主动脉内球囊反搏，支持22－25h（平均42h）。手术后呼吸机支持4h－18d（平均7．3d）合并消化道出血4例，肾功能不全2例，肺部感染2例，切口感染1例。手术后住院时间12－35d，平均21d。全组均痊愈出院。结论：冠状动脉搭桥围术期急性心肌梗死应重在预防。如怀疑桥有问题，急诊再搭桥是良好选择，但手术后并发症发生率明显增加。     

Percutaneous transluminal coronary angioplasty in patients with prior coronary artery bypass grafting: ten years' experience

We evaluated the acute and long-term results of percutaneous transluminal coronary angioplasty in 140 patients with prior coronary artery bypass grafting treated over a 10-year period (1981–1991). Angioplasty was technically successful in 85% of 122 nonoccluded native vessels and in 86% of 50 saphenous vein grafts. Two patients (1.4%) had a myocardial infarction and there were three procedure-related deaths (2.1%). The cumulative probability of survival was 91.5% and 74.5% at 1 and 5 years, respectively. Survival free from myocardial infarction and repeat bypass grafting at 1 and 5 years was 77.3% and 53.9%, respectively. At census, 31% of the 117 survivors were asymptomatic, and 47% were improved by at least two angina grades. Coronary angioplasty provides an apparently safe and effective alternative method of revascularization in selected patients with prior coronary artery bypass grafting. This treatment strategy potentially avoids reoperation with its attendant risks. © 1994 Wiley-Liss, Inc.     

Usefulness of myocardial ischemia as predictor of training effect in cardiac rehabilitation after acute myocardial infarction or coronary artery bypass grafting

Exercise capacity increases to a variable degree in coronary patients during cardiac rehabilitation. The effect of baseline exercise-induced ischemia on the response to a 12-week conditioning program was evaluated in 106 coronary patients. The magnitude of exercise conditioning response was greater in nonischemic patients than in ischemic patients, with maximal exercise intensity increasing 69 versus 50% (7.2 to 12.1 vs 7.1 to 10.6 METs) (p less than 0.05) and maximal oxygen consumption increasing 28 versus 10% (23.1 to 29.6 vs 23.0 to 25.4 cc/kg/min) (p less than 0.05). Markers of conditioning during submaximal exercise such as heart rate and heart rate-systolic blood pressure product were similarly reduced in both groups. The groups did not differ by age, diagnosis, resting ejection fraction, incidence of beta-blocker use, maximal exercise capacity, maximal exercise heart rate, blood pressure or intensity of actual exercise training. These results suggest that exercise-induced ischemia alters the stimulus to adapt to exercise training.     

Extraction atherectomy during myocardial infarction in a patient with prior coronary artery bypass surgery

Directional coronary atherectomy has recently become available to treat coronary stenosis by excision and removal of tissue. The optimal depth of resection by this method has not been determined and complications have occurred. This report describes the formation of a coronary aneurysm at an atherectomy site in an asymptomatic patient, a finding not reported previously.     

冠脉旁路移植术后再发急性心肌梗死136例临床分析

目的:评估冠脉旁路移植术后再发急性心肌梗死(AMI)患者冠脉造影特点和成功再血管化对预后的影响。方法:回顾性分析136例行冠脉旁路移植术后再发AMI患者(包括STEMI和NSTEMI)冠脉造影特点、临床表现、心电图和心脏彩超特征。结果:91.7%的STEMI患者和57.1%的NSTEMI患者罪犯血管是桥血管(P=0.001),其中,静脉桥血管是罪犯血管的比例超过动脉桥血管(210根静脉桥中82根vs 165根动脉桥中4根,P0.001)。自体冠状动脉100%成功行经皮冠状动脉介入术(PCI),桥血管成功行PCI 86.1%(P=0.002)。院内病死率8.1%,其中STEMI患者病死率16.7%,NSTEMI患者病死率6.3%(P=0.104)。PCI成功患者病死率3.3%,PCI失败患者病死率70%(P0.001)。结论:冠脉旁路移植术后再发AMI患者,罪犯血管更有可能是静脉桥血管,自体冠状动脉行PCI的成功率更高,成功行PCI术能显著降低病死率。     

Coronary angioplasty in patients with previous coronary artery bypass grafting.

Between 1982 and 1990, in 134 patients with prior coronary artery bypass grafting and recurrent angina, repeat coronary angiography and balloon angioplasty of stenoses in grafts or native arteries were attempted. Mean age of grafts was 45.6 months, range three days to twelve years. At the time of angioplasty, 6 patients had one-vessel-disease, 33 had two-vessel-disease, and 95 had three-vessel-disease. A total of 182 lesions were dilated: 55 venous grafts, 3 internal mammary artery grafts, and 124 native vessels. Forty-nine of 55 (89%) venous grafts could be successfully dilated, and in 3 internal mammary artery grafts, a stenosis reduction greater than 50% was achieved. In 65 of 88 (74%) grafted native arteries, dilation success was achieved. Twenty-seven of 36 (75%) patients with prior bypass surgery to other arteries had successful angioplasty of nongrafted native arteries. Three patients underwent emergency bypass surgery after dissection and acute occlusion: one of them died in cardiogenic shock secondary to acute myocardial infarction. The angiographic success rate in grafts was slightly higher than in native arteries (90% vs 74%). These data indicate that percutaneous transluminal coronary angioplasty in patients after bypass surgery is possible at a low risk (3%) and constitutes an effective therapy in symptomatic patients.     

伴卒中史患者非体外循环冠状动脉旁路移植术后再发急性脑梗死的影响因素分析

目的探讨伴有卒中史患者非体外循环冠状动脉旁路移植(OPCAB)术后再发急性脑梗死的相关因素。方法回顾性分析首都医科大学附属北京安贞医院2010年1月—2012年9月,468例有卒中史OPCAB手术患者的临床资料。根据术后有无再发急性脑梗死分为再发脑梗死组(A组)41例和无再发脑梗死组(B组)427例。分析与缺血事件发生的相关因素[术后再发脑梗死的时间为完成手术入住重症监护病房(ICU)期间]。结果 468例OPCAB手术患者术后再发急性脑梗死41例,占8.8%。①单因素分析显示,A、B组间术前双侧颈内动脉重度狭窄[(41.5%(17/41),8.9%(38/427)]、术前左心室射血分数≤35%[53.7%(22/41),25.8%(110/427)]、术中En-closeⅡ主动脉近端吻合器的应用[19.5%(8/41),76.3%(326/427)]、术后急性心肌梗死[34.1%(14/41),9.1%(39/427)]、术后心房颤动[48.8%(20/41),10.8%(46/427)]、术后低血压[68.3%(28/41),18.7%(80/427)]、术后机械通气时间>72 h[(75.6%(31/41),15.0%(64/427)]、入住ICU时间>72 h[(82.9%(34/41),25.3%(108/427)]及病死率[(29.3%(12/41),5.4%(23/427)],差异均有统计学意义(均P<0.01)。②多因素Logistic回归分析显示,术前双侧颈内动脉重度狭窄(OR=6.338,95%CI:2.283～21.019)、术前左心室射血分数≤35%(OR=2.737,95%CI:1.267～6.389)、术后急性心肌梗死(OR=3.656,95%CI:1.933～6.894)、术后心房颤动(OR=3.104,95%CI:1.135～8.016)与术后低血压(OR=4.173,95%CI:1.836～9.701)是OPCAB患者术后再发急性脑梗死的独立危险因素。术中应用EncloseⅡ主动脉近端吻合器(OR=0.556,95%CI:0.337～0.925)是OPCAB患者术后再发急性脑梗死的保护因素。结论伴有卒中史患者行OPCAB术后,再发急性脑梗死的发生率及病死率高,术前双侧颈内动脉重度狭窄、术前左心室射血分数≤35%、术后急性心肌梗死、术后心房颤动和术后低血压是伴有卒中史患者OPCAB术后再发急性脑梗死的独立危险因素。而术中应用EncloseⅡ主动脉近端吻合器是伴有卒中史患者OPCAB术后再发急性脑梗死的保护因素。     

Balloon coronary angioplasty in patients with acute myocardial infarction

After successful thrombolysis, approximately 75% of all patients will have significant coronary stenosis, which can be dilated by means of percutaneous transluminal balloon angioplasty (PTCA). In a randomized control study, 95 of our patients (Group I) had thrombolysis alone, whereas 95 others (Group II) had thrombolysis and PTCA. Both groups were comparable with respect to age, sex, infarct location, and maximal creatine kinase (CK) value. The clinical outcome during the hospital phase was better in Group II, which had a reocclusion rate of 13%, a reinfarction rate of 5%, a lethal reinfarction rate of 2%, and a cardiac death rate of 7%, compared with respective rates of 20%, 13%, 7%, and 13% in Group I. Furthermore, in Group I, residual coronary stenosis immediately after thrombolysis (75% +/- 20%) did not improve significantly until the end of the hospital phase, when it decreased to 69% +/- 21%. In Group II, stenosis (78% +/- 16%) was improved by PTCA to 33% +/- 21%, and this improvement remained constant during the hospital phase (30% +/- 26%). In Group-II patients who had an unsuccessful PTCA, stenosis was approximately the same before dilatation (83% +/- 12%), after dilatation (80% +/- 17%), and at the control study (83% +/- 17%). The end-diastolic, end-systolic, and stroke volume indices, as well as the ejection fraction, also remained unchanged. In Group I, the number of pathologic wall segments (12.2 +/- 5.0) did not improve during the hospital phase (12.2 +/- 7.9), but in Group II, the improvement was significant (14.0 +/- 5.7 vs. 10.9 +/- 8.2) (p < 0.05). PTCA seems to improve the clinical outcome, reduce the infarction and mortality rates, and enhance myocardial perfusion and performance.     

Outcome of acute ST-segment elevation myocardial infarction in patients with prior coronary artery bypass surgery receiving thrombolytic therapy

BACKGROUND: Patients with prior coronary bypass surgery with acute ST-segment elevation myocardial infarction (MI) pose an increasingly common clinical problem. We assessed the characteristics and outcomes of such patients undergoing thrombolysis for acute MI. METHODS AND RESULTS: We compared the characteristics and outcomes of patients in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial (GUSTO-I) who had had prior bypass (n = 1784, 4% of the population) with those without prior coronary artery bypass grafting (CABG), all of whom were randomized to receive one of four thrombolytic strategies. Patients with prior bypass were older with significantly more prior MI and angina. Overall, 30-day mortality was significantly higher in patients with prior bypass (10.7% vs 6.7% for no prior bypass, P <.001); these patients also had significantly more pulmonary edema, sustained hypotension, or cardiogenic shock. Patients with prior bypass showed a 12.5% relative reduction (95% confidence interval, 0% to 41.9%) in 30-day mortality with accelerated alteplase over the streptokinase monotherapies. In the 62% of patients with prior CABG who underwent coronary angiography, the infarct-related vessel was a native coronary artery in 61.9% and a bypass graft in 38.1% of cases. The Thrombolysis in Myocardial Infarction (TIMI) 3 flow rate was 30.5% for culprit native coronary arteries and 31.7% for culprit bypass grafts. Patients with prior bypass had more severe infarct-vessel stenoses (99% [90%, 100%] vs 90% [80%, 99%], P <.001). CONCLUSIONS: The 30-day mortality in patients with prior CABG was significantly higher than that for patients without prior CABG. As in the overall trial, these patients derived an incremental survival benefit from treatment with accelerated alteplase, but mortality remained high (16.7%) at 1 year. These results are at least partially explained by the higher baseline risk of these patients and by the lower rate of patency of the infarct-related artery.