Secondary prevention after coronary artery bypass grafting--what do we know?

There is insufficient knowledge about secondary prevention after coronary artery bypass grafting (CABG). Most of it is gathered from patients suffering from myocardial infarction and angina pectoris, only a minority of whom have undergone CABG. Whereas it seems clear that these patients should give up smoking and reduce low-density lipoprotein (LDL) cholesterol, there is uncertainty about the optimal antiplatelet regimen and antithrombotic treatment. There are some data indicating the benefit of behaviour modification. There is room for improvement and more knowledge when it comes to secondary prevention after CABG.     

Serum Cholesterol,Lifestyle, Working Capacity and Quality of Life in Patients with Coronary Artery Disease. Experiences from a Hospital-based Secondary Prevention Programme

Coronary artery diseases (CAD) are main causes of morbidity and hospitalisation in western countries and CAD patients are at considerable risk of suffering further cardiac events. The development and evaluation of secondary prevention programmes therefore an important task. This thesis includes investigations on CAD patients admitted to a secondary prevention programme at Malmö University Hospital, Malmö, Sweden. Four weeks after discharge from the hospital, consecutive male and female patients aged 50-70 years with acute myocardial infarction (AMI) or treated with coronary artery bypass grafting (CABG) surgery were randomised to a hospital organised preventive intervention or to usual follow-up at their general practitioners. In the three studies using this randomised design, 87 (study II), 90 (study IV), and 106 (study V) intervention patients were available for evaluation. In addition, without randomisation, lipid levels at four weeks after the event was compared with levels estimated within 24 hours after onset of symptoms in 141 AMI patients (study I), and quality of life (QL) were estimated by questionnaire at one month and at one year after the event in 266 AMI, 94 CABG, and 16 percutaneous transluminal coronary angioplasty (PTCA) patients (study III). The prevention programme was effective in improving food habits but showed no impact on smoking habits or physical exercise in AMI patients (study II). The intervention also did not show any significant improvement in working capacity in AMI and CABG patients. However, working capacity improved in both intervention and reference CABG patients, most probably due to improved coronary circulation from the surgery (study IV). Cholesterol levels decreased significantly in AMI and CABG intervention patients as compared to the corresponding reference patients. This difference most likely was due to a higher frequency of lipid lowering drugs used in the intervention patients (study V). The prevention programme also decreased body mass index significantly in AMI but not in CABG patients (study V). In AMI patients receiving thrombolysis, cholesterol levels estimated within 24 hours after onset of symptoms and at four weeks after the event were virtually equal. In AMI patients not receiving thrombolysis, the lipid estimates from four weeks after the event were slightly, but significantly, above the within 24 hours from onset of symptoms estimates (study I). One month after the event, both somatic and psychological aspects of QL were negatively affected in AMI and CABG patients compared to population controls. One year after the event, patients differed from controls mainly in somatic symptoms (study III). Thus, the intervention programme was most successful in affecting lipid levels and food habits in AMI patients. QL was considerably affected in patients following an cardiac event, especially during the initial recovery phase. In addition, in patients receiving thrombolysis, cholesterol levels estimated four weeks after an AMI are reasonably valid estimates of baseline values and may be used to decide about lipid lowering interventions.     

Oral cibenzoline reduces postoperative atrial fibrillation in coronary artery bypass grafting

OBJECTIVE: The objective of the present study was to investigate the effectiveness of postoperative oral administration of cibenzoline for the prevention of atrial fibrillation (AF) in coronary artery bypass grafting (CABG). METHODS: A total of 39 patients who underwent isolated CABG from September 2000 to February 2001 and who took oral cibenzoline (300 mg per day for 10 days beginning immediately after surgery) were compared to 59 patients who underwent surgery in our department 8 months prior to the study and who did not take cibenzoline for incidence of postoperative AF. Exclusion criteria encompassed age (>80 years), low ejection fraction (<30%), high serum creatinine level (>2.0 mg/dL), and history of supraventricular arrhythmia with or without treatment by anti-arrhythmic drugs. RESULTS: Postoperative AF occurred in 2 patients in the cibenzoline group (2/35, 5.7%) and 20 patients in the control group (20/59, 33.9%). There were significant differences in the incidence of postoperative AF (p = 0.002). Multivariate analysis revealed that the administration of cibenzoline reduced the incidence of AF significantly, and that a large number of bypass grafts significantly contributed to postoperative AF in CABG. The number of bypass grafts was significantly larger in the cibenzoline group, indicating that cibenzoline administration significantly suppresses the incidence of AF after CABG in high-risk patients. CONCLUSIONS: Postoperative administration of oral cibenzoline for 10 days is one effective method for the prevention of AF after CABG.     

The influence of asymptomatic significant carotid disease on mortality and morbidity in patients undergoing coronary artery bypass surgery.

OBJECTIVES: Controversy exists regarding the optimal management of patients with coexisting coronary and extracranial carotid artery disease. This study investigates the incidence of death, cerebrovascular events and myocardial infarction (MI) in patients with asymptomatic significant carotid artery disease undergoing coronary artery bypass graft (CABG) surgery. DESIGN: Prospective cohort. METHODS: Fifty patients with asymptomatic carotid stenoses > or =70% associated with cervical bruits undergoing CABG without prophylactic carotid endarterectomy (CEA) were followed up over a median period of 68 months following surgery cerebrovascular events, MI and mortality were recorded. All patients received optimal secondary prevention for cardiovascular disease unless contraindicated. RESULTS: No cerebrovascular events occurred within 30 days of surgery. One patient suffered an ipsilateral transient ischaemic attack (TIA) 14 months after CABG. Two patients died within 30 days; one from an MI, the other from pancreatitis. Three deaths occurred after 30 days; one from MI, one from primary lung cancer and one following rupture of an abdominal aortic aneurysm. No non-fatal MIs occurred. CONCLUSIONS: In this patient group the overall risk of death, cerebrovascular events and MI was 4% during the first 30 days postoperatively and 8% thereafter. This compares favourably with published series for staged or combined CEA-CABG procedures. For asymptomatic significant carotid disease, prophylactic CEA prior to CABG does not appear to confer any advantage over CABG alone.     

Magnesium in addition to sotalol does not influence the incidence of postoperative atrial tachyarrhythmias after coronary artery bypass surgery

OBJECTIVE: Postoperative atrial tachyarrhythmias (POATs) after coronary artery bypass grafting (CABG) are reported in 11% to 40% of patients. Several etiologic factors are mentioned. Prophylactic intervention with sotalol is reported to reduce the incidence of POAT. The authors studied the effect of magnesium chloride (MgCl2) in addition to sotalol in the prevention of POAT. DESIGN: Prospective, randomized, double-blinded, placebo-controlled trial. SETTING: Single center. PARTICIPANTS AND INTERVENTIONS: After institutional approval and written informed consent, patients undergoing CABG with use of cardiopulmonary bypass were included in a prospective, randomized, placebo-controlled double-blind study. In 74 patients, intravenous MgCl2, 50 mmol/24 hours, was continuously administered after the induction of anesthesia during 36 hours; 73 patients received placebo. In both groups, sotalol orally was started 16 to 24 hours after CABG. The incidence and duration of in-hospital POAT were evaluated. MEASUREMENTS AND MAIN RESULTS: A total of 147 patients could be evaluated: in the magnesium-treated group (n = 74), 25 patients developed POAT (34%) and in the placebo group (n = 73) 19 patients (26%) (p = 0.36). There was no statistically significant difference in duration of POAT between the groups. In the magnesium-treated group, 9 patients experienced serious bradyarrhythmias (12%), and in the placebo group no serious bradyarrhythmias were observed (p = 0.003). There was no mortality in either group. CONCLUSIONS: These results show that MgCl(2), in addition to sotalol, is not more effective than sotalol alone in the prevention of tachyarrhythmias after CABG. The data showed that this combination may also induce serious bradyarrhythmias.     

Coronary artery bypass grafting with gastroepiploic artery composite graft

BACKGROUND: To achieve better results after coronary artery bypass grafting (CABG), arterial conduits are the first choice in multiple CABG for younger patients. We present here the early results of CABG with gastroepiploic artery (GEA) composite graft with free radial artery (RA) to revascularize right coronary artery or left circumflex artery in addition to internal thoracic artery to left anterior descending artery. METHODS: Between July 1997 and June 1998, 13 patients received CABG with GEA (larger caliber than 2.0 mm) composite graft. We have assessed the early results. RESULTS: There was no postoperative death or major morbidity. Postoperative angiogram was performed in 11 patients and all conduits were patent. Postoperative exercise stress test was done in 13 cases and showed no ischemia. CONCLUSIONS: Multiple CABG with arterial conduit can be performed by this procedure. The free RA functioned from secondary branches derived from proximal GEA. In conclusion, this procedure seems to be safe and effective, and both long-term patency and better quality of life may be expected.     

Long-term results of chronic hemodialysis patients with isolated coronary artery bypass grafting performed by the same surgeon. A comparative study

BACKGROUND: The aim of this study was to examine the long-term results of isolated coronary artery bypass grafting (CABG) patients who required chronic hemodialysis. METHODS: From May 1990 to June 2000, 23 hemodialysis patients received isolated CABG performed by the same surgeon. Postoperative follow-up was completed with maximum duration of 122 months. RESULTS: Operative deaths (n=2) were due to acute circulatory failure related to hemodialysis. The most frequent cause of late deaths (n=10) was infection. Five (50%) patients died of sepsis, and 80% of sepsis was caused by leg infection associated with arteriosclerosis obliterans. There were 6 late cardiac events including 3 cardiac deaths. The actual survival rates 1, 3, 5 and 7 years after CABG were 68.6%, 42.5%, 35.4% and 35.4%, respectively. And the actual cardiac event free rates 1, 3, 5 and 7 years after CABG were 77.6%, 77.6%, 46.6% and 46.6%, respectively. Operative mortality (p=0.019), long-term survival (p<0.001) and cardiac event free rate (p=0.002) were significantly poorer in hemodialysis patients than in non-hemodialysis patients. However, the long-term survival rate of our hemodialysis patients receiving isolated CABG was almost similar to that in dialysis patients without CABG. The etiology of chronic renal failure did not significantly affect long-term RESULTS. Using internal thoracic artery graft significantly (p=0.02) decreased the late cardiac event in hemodialysis patients, although it did not improve late survival. CONCLUSIONS: Primary CABG followed by aggressive re-intervention have the benefit of preventing late cardiac death in hemodialysis patients. However, prevention of sepsis and treatment of arteriosclerosis obliterans are important for improving the late survival in hemodialysis patients receiving isolated CABG.     

冠状动脉旁路移植术后早期紧急再次手术

目的 探讨冠状动脉旁路移植(CABG)术后围术期急性心肌缺血的病因和外科治疗.方法 2001年1月至2009年1月,28例CABG术后早期进行了紧急再次手术.其中男18例,女10例.平均年龄54岁.主要病因包括早期移植物栓塞、乳内动脉(IMA)异常、靶血管吻合口异常,桡动脉(RA)痉挛、心肌血管化不完全.首次手术到再次手术时间间隔1～48 h,平均8 h.紧急再次手术中仅2例选择非体外循环不停跳手术,余均在体外循环心脏停跳下CABG.再次手术包括:对异常移植物尽可能去除,选择重新吻合或远端加一旁路血管.对RA持续痉挛者拆除后用静脉再次行旁路手术.再次手术中给予充分再血管化.结果 手术死亡2例.术后1～14天死亡8例.16例术后放置主动脉内球囊反搏(IABP)辅助,其中2例同时进行体外膜式氧合器(ECMO)辅助,2例同时选择左心辅助装置(LVAD).18例生存者均无严重并发症.结论 CABG术后早期急性严重心肌缺血病死率高.早期诊断和及时外科处理可以提高生存率.强调术前、术后预防的重要性.

Abstract：

Objective To explore the cause of acute myocardial ischemia early after coronary artery bapass graft (CABG) and surgical management on it. Methods From 2001 to 2009, 28 patients underwent urgent reoperation early after CABG due to acute myocardial ischemia. The incidence of reoperation is about 0.02%. The cause of reoperation inclouded early graft occlusion (10 cases) ,IMA damage or injury during harvesting(9 cases), inexactitude distal anastomosis(2 cases)and radial artery spasm(4 cases). The mean interval time between two operations was 8 hours. Reoperation was done under offpump bypass in 2 patients and on-bypass used in other patients. Unsatisfactoey graft were substituted with new graft material and thrombotic was removed. If LIMA was the reson for myocardial ischemia, an additional vein graft was inserted. The spasm radial artery were substituted with new vein graft. Completely revascularization was used in re-do CABG. Results Two patients died during reoperation. 8 patients was died between 1 day and 14 days after reoperation. IABP was used in 16 patients,which 2 patients received ECMO suppord and 2 patient received LVAD suppord at mean time. Conclusion There have very high mortality in acute myocardial ischemia early after CABG. The early diagnosis and correct surgical management can improve the rates of survival. The active prevent should be emphasized during the first CABG.     

Fast-track management for conventional coronary artery bypass surgery

BACKGROUND: Recent introduction of off-pump coronary artery bypass grafting (CABG) emphasizes the advantage of early hospital discharge. Fast-track management using epidural block and autologous fresh blood transfusion might be possible in conventional CABG. METHODS: Fast-track anesthesia using high thoracic and lumbar epidural analgesia and pre-CPB autologous fresh blood transfusion was used in 19 patients undergoing on-pump CABG. RESULTS: Mean blood-loss was about 283 (+/-140) ml during 6 hours after surgery. Nine patients were extubated in the operating room, two cases in one hour, and six cases in 6 hours after surgery. Seventeen patients could have lunch or supper the day after surgery. CONCLUSIONS: These techniques allowed early extubation and early drinking after on-pump CABG surgery. There were no complications in these patients.     

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from grastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.     

Oral cibenzoline reduces postoperative atrial fibrillation in coronary artery bypass grafting

Objective The objective of the present study was to investigate the effectiveness of postoperative oral administration of cibenzoline for the prevention of atrial fibrillation (AF) in coronary artery bypass grafting (CABG). Methods: A total of 39 patients who underwent isolated CABG from September 2000 to February 2001 and who took oral cibenzoline (300 mg per day for 10 days beginning immediately after surgery) were compared to 59 patients who underwent surgery in our department 8 months prior to the study and who did not take cibenzoline for incidence of postoperative AF. Exclusion criteria encompassed age (>80 years), low ejection fraction (<30%), high serum creatinine level (>2.0 mg/dL), and history of supraventricular arrhythmia with or without treatment by anti-arrhythmic drugs. Results: Postoperative AF occurred in 2 patients in the cibenzoline group (2/35, 5.7%) and 20 patients in the control group (20/59, 33.9%). There were significant differences in the incidence of postoperative AF (p=0.002). Multivariate analysis revealed that the administration of cibenzoline reduced the incidence of AF significantly, and that a large number of bypass grafts significantly contributed to postoperative AF in CABG. The number of bypass grafts was significantly larger in the cibenzoline group, indicating that cibenzoline administration significantly suppresses the incidence of AF after CABG in high-risk patients. Conclusions: Postoperative administration of oral cibenzoline for 10 days is one effective method for the prevention of AF after CABG. Read at the Fifty-fourth Annual Meeting of The Japanese Association for the Thoracic Surgery, Oral Session, Osaka October 3–5, 2001.     

Operative and early results of coronary artery bypass grafting in female patients in different body mass indexes

Background  

Female gender has been reported to be an independent risk factor for coronary artery bypass grafting (CABG) in European System for Cardiac Risk Evaluation. The effect of the body size on the CABG outcome is less clear. There is ongoing debate about obesity as a risk factor for adverse outcomes after cardiovascular procedures. The goal of this retrospective study is to evaluate the in hospital and early postoperative outcomes in severe obese, obese and normal-slightly obese female patients after CABG.     

Common carotid intima-media thickness measurement is not a pertinent predictor for secondary cardiovascular events after coronary bypass surgery. A prospective study.

OBJECTIVE: We aimed to assess the utility of common carotid intima-media thickness (CCA-IMT) to predict secondary cardiovascular events after coronary artery bypass grafting (CABG). In primary prevention, carotid-IMT is known as a valuable cardiovascular risk marker, but its interest in secondary prevention has been less studied. We hypothesized that CCA-IMT could be used for peri-operative and long-term risk stratification in candidates for CABG. METHODS: A total of 609 patients (66.8+/-9.2 years) were prospectively enrolled for preoperative CCA-IMT measurement and follow-up. The primary end-point combined cardiovascular death, non-fatal acute coronary syndromes, stroke, secondary coronary revascularization and peripheral arterial surgery during follow-up. The secondary end-point was the 1-month post-operative death. Univariate and multivariate analysis were performed by usual methods. RESULTS: A subgroup of 150 patients (24.6%) was individualized with a CCA-IMT above 90th percentile (>0.90 mm) or presenting plaques in their CCA. At 1 month, there was no significant difference in the prevalence of elevated CCA-IMT between deceased patients and survivors (16.7 vs. 24.9%, P=ns). During a mean follow-up of 41.8+/-16 months, 121 patients (19.8%) met the primary end-point. High CCA-IMT was predictive (OR=1.67, 95% CI 1.14-2.46, P=0.009) in the univariate analysis. In the multivariate analysis, age (OR=1.03, 95% CI 1.00-1.05, P=0.029) concomitant valvular surgery (OR=2.17, P=0.003) arrhythmia (OR=2.20, P=0.021), and peripheral arterial disease (OR=2.41, P<0.001) were significant independent prognostic factors whereas CCA-IMT failed to remain independently significant. CONCLUSIONS: Pre-operative CCA-IMT can provide prognostic information for candidates to CABG. However, clinical data present stronger prognostic values.     

Severe systemic cholesterol embolization after open heart surgery

Cholesterol crystal embolization (CCE) may be triggered by various factors: intra-arterial angiographic procedures, aortic or vascular surgery, anticoagulant or thrombolytic treatments, or both. There are few previous reports of patients undergoing coronary artery bypass grafting (CABG) experiencing and therefore displaying severe systemic CCE. We describe four patients presenting, shortly after CABG, cutaneous, renal, neurological and hepatic signs related to severe CCE confirmed by skin biopsy. All patients died 11-92 days after surgery. As systemic CCE reveals severe atheromatous disease and is associated with a poor prognosis, it is advisable to avoid CABG in patients who present symptoms of CCE before surgery.      

Risk factor awareness and secondary prevention of coronary artery disease: are we doing enough?

We prospectively assessed the patient awareness of risk factors of coronary artery disease (CAD) in this study by performing a voluntary questionnaire survey of 235 patients undergoing first time coronary artery bypass grafting (CABG) between May and December 2003. We assessed patient awareness of smoking, hypertension (HT), hypercholesterolaemia (HC), obesity, family history (FM) and diabetes (DM) and role of medication in secondary prevention. One hundred and eighty-seven ex- or current smokers (79.6%), 175 hypercholesterolaemic (74.5%), 116 had a family history (49.4%), 88 were hypertensive (37.4%), 62 obese (26.4%) and 45 diabetic (19.1%). More patients identified smoking (53.6%) and hypercholesterolaemia (55.3%) as risk factors as compared to hypertension (43%), family history (42.5%), diabetes (14.5%) or obesity (13.6%). A majority of the patients identified their own risk factors correctly. More than 95% of the patients were taking aspirin/clopidogrel and/or a statin. The main sources of information for these patients were hospitals, general practitioners, and booklets. Risk factor awareness in patients undergoing CABG is unsatisfactory. Nearly 95% of patients are taking aspirin/clopidogrel and/or statins, however, just over half realise their role in secondary prevention. For secondary prevention to be effective, more needs to be done to provide patients with necessary information.     

Coronary arterial revascularization in dialysis patients

It is recently reported that among chronic renal dialysis patients myocardial infarction accounts 7.4% of all the cause of death in Japan. In order to improve the mortality of dialysis patients the treatment of ischemic heart disease (IHD) is a major problem. We review previous reports and discuss about the treatment of IHD in dialysis patients. The collected data from the previous reports written about CABG in dialysis patients shows that the mortality of CABG is 7.8% (30/387), the probability of perioperative myocardial infarction (PMI) 8.6% (21/243), brain infarction 1.6% (4/243) and major infection 5.8% (14/243). 3-year and 5-year mortality rate after CABG is reported to be 69-80% and 48-56%, respectively. The result of CABG is excellent and shows that this procedure improves the mortality of dialysis patients with IHD. The procedural mortality of PTCA is 5.6% (8/143), the probability of PMI is 7% (10/143). Many reports shows the high probability of the recurrence of chest pain (60-86%). This procedure when performed in dialysis patients is incomplete because of the calcification of the coronary artery. Even among the dialysis patients it is preferable to perform CABG positively.     

Optimal treatment for coronary artery disease in patients with diabetes: percutaneous coronary intervention,coronary artery bypass graft,and medications

There are three strategies for patients with coronary artery disease (CAD): medical therapy, coronary artery bypass graft (CABG), and percutaneous coronary intervention (PCI). With the development of drug-eluting stents, PCI is now widely used as the firstline treatment around the world. The advantage of CABG over PCI, however, remains in patients with left main coronary artery disease, three-vessel disease, and diffuse CAD. PCI and CABG do not exist in isolation because relieving the symptoms of angina is not the goal of treatment of CAD. Secondary prevention with vigorous modification of risk factors should be initiated and maintained. Among coronary risk factors, diabetes mellitus (DM) remains the most important one to predict poor early and late outcomes even in patients undergoing complete revascularization with CABG. Lowering the blood glucose level is important, but strict glycemic control is not necessarily associated with further reduction of cardiovascular events. Modification of insulin resistance with pioglitazone and metformin, lipid-lowering therapy with a statin, lowering blood pressure to <130/80 mmHg, and antiplatelet therapy should be considered in individuals with DM. A major concern is suboptimal modifications of risk factors in patients with DM and CABG in the real world. We should bear in mind this treatment gap and provide medical therapy for patients who need it most.     

Use of perioperative cardiac medical therapy among patients undergoing coronary artery bypass graft surgery

BACKGROUND: Previous studies have demonstrated that cardiac medical therapy is associated with improved clinical outcomes in noncardiac surgery. However, the use of these agents among patients undergoing coronary artery bypass graft (CABG) remains poorly understood. METHODS: We described the in-hospital medication use among 2,389 consecutive patients who underwent CABG at three North American hospitals. Demographic, clinical, and medication use information was extracted from resource and cost accounting systems at each hospital. We examined use of aspirin, angiotensin-converting-enzyme (ACE) inhibitors, beta blockers, and statins during the following seven in-hospital periods: admission, presurgery, the day before surgery, the day of surgery, the day after surgery, postsurgery, and discharge. RESULTS: Medication use throughout hospitalization was low among patients undergoing CABG. Use of ACE inhibitors and statins on the day of surgery was <10%, while aspirin and beta blocker use on the day of surgery was 43.0% and 42.9%, respectively. The use of cardiac medical therapy at hospital discharge was also low (ACE inhibitors: 23.0%; aspirin: 74.9%; beta blockers: 58.9%; and statins: 28.2%). The use of cardiac medical therapy at discharge appeared to increase over time. CONCLUSION: In-hospital cardiac medical therapies are underused among patients undergoing CABG. This is particularly true at discharge, where the benefits of these agents for secondary prevention are well established.     

Early myocardial revascularization for postinfarction angina

In 1983 and 1984, coronary artery bypass grafting (CABG) was performed on 107 consecutive patients for postinfarction angina. In each instance, CABG was done within 30 days of infarction. Sixty-three patients (59%) required intravenous administration of nitroglycerin and/or the intraaortic balloon pump (IABP) for relief of angina. Oral medications relieved angina in the remaining 44 patients. Thirty-eight patients underwent CABG 7 days or less after the infarction (Group 1), 25 received it between 8 and 15 days later (Group 2), and 44 had CABG between 16 and 30 days later (Group 3). There were 9 in-hospital deaths: 4 in Group 1, 2 in Group 2, and 3 in Group 3. Thirteen patients needed the IABP for hemodynamic stability as well as relief of angina. Even when the patient was stable hemodynamically, death was more likely to occur among these 13 patients if CABG was conducted within 7 days of infarction. Follow-up was 94% complete at 29.4 months. Eighty-six percent of patients were asymptomatic or in New York Heart Association Functional Class I, and 6% were in Class II. There were 2 late deaths. CABG for angina can be accomplished within 30 days of an acute infarction with good results. The exception to this rule is the patient in whom shock develops after a myocardial infarction and who, despite stabilization, receives CABG within 7 days of the infarction.     

A randomized, double-blind, placebo-controlled trial of a COX-2 inhibitor (Rofecoxib) in patients undergoing coronary artery bypass surgery

The endothelium of patients with coronary artery disease shows increased expression of cyclooxygenase-2 (COX-2) during coronary artery bypass graft surgery (CABG) using cardiopulmonary bypass. This, together with serotonin, may lead to coronary microvessel spasm, which potentially, can contribute to myocardial ischemia and injury after surgery. We performed a randomized, double-blind, placebo-controlled trial in patients undergoing isolated CABG to determine whether short-term treatment with a selective COX-2 inhibitor, Rofecoxib (25 mg), given preoperatively and for 5 days after operation, can offer better myocardial protection in patients undergoing CABG by measuring serial cardiac troponin T (cTnT) levels. The study was powered to recruit 150 consecutive patients undergoing isolated CABG but the study was terminated prematurely by the worldwide withdrawal of rofecoxib. There were highly statistically significant (P<0.001) increases in cTnT in both groups at each time point (1, 6, 24 and 48 h after onset of cardiopulmonary bypass) compared to preoperative levels. cTnT levels were similar at all post-operative time points between the 2 groups. There is no evidence that short-term treatment with rofecoxib has a myocardial protective effect in patients undergoing CABG. There is also no evidence that its effect is deleterious to the myocardium in patients undergoing CABG.