Timing of in-hospital coronary artery bypass graft surgery for non-ST-segment elevation myocardial infarction patients results from the National Cardiovascular Data Registry ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network

The aim of this study was to examine timing of in-hospital coronary artery bypass graft surgery (CABG) for non-ST-segment elevation myocardial infarction (NSTEMI) patients. Although practice guidelines recommend delaying CABG for a few days after presentation for ST-segment elevation myocardial infarction patients, current guidelines for NSTEMI patients do not address optimal CABG timing. We evaluated rates and timing of in-hospital CABG among NSTEMI patients treated at U.S. hospitals from 2002 to 2008 with the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) (January 2002 to December 2006) and ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines) (January 2007 to June 2008) programs. Analyses designed to study the clinical characteristics and outcomes of early (<or=48 h, n = 825) versus late (>48 h, n = 1,822) CABG focused upon more recent NSTEMI patients from the ACTION Registry-GWTG. Both the rate (11% to 13%) and timing (30% early and 70% late) of in-hospital CABG remained consistent from 2002 to 2008. In the ACTION Registry-GWTG program, NSTEMI patients undergoing late CABG tended to have a higher risk profile than those undergoing early CABG. In-hospital mortality (3.6% vs. 3.8%, adjusted odds ratio: 1.12, 95% confidence interval: 0.71 to 1.78) and the composite outcome of death, myocardial infarction, congestive heart failure, or cardiogenic shock (12.6% vs. 12.4%, adjusted odds ratio: 0.94, 95% confidence interval: 0.69 to 1.28) were similar between patients undergoing early versus late CABG. Most NSTEMI patients undergo late CABG after hospital arrival. Although these patients have higher-risk clinical characteristics, they have the same risk of adverse clinical outcomes compared with patients who undergo early CABG. Thus, delaying CABG routinely after NSTEMI might increase resource use without improving outcomes. Additionally, the timing of CABG for NSTEMI patients might be appropriately determined by clinicians to minimize the risk of adverse clinical events.

Parikh SV ，de Lemos JA ，Jessen ME ，Brilakis ES ，Ohman EM ，Chen AY ，Wang TY ，Peterson ED ，Roe MT ，Holper EM ，CRUSADE and ACTION Registry-GWTG Participants ... -  《-》

Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non-ST Elevation Myocardial Infarction: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention O

Current guidelines recommend surgical revascularization (coronary artery bypass graft [CABG]) over percutaneous coronary intervention (PCI) in patients with diabetes mellitus and multivessel coronary artery disease. Few data are available describing revascularization patterns among these patients in the setting of non-ST-segment-elevation myocardial infarction. Using Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (ACTION Registry-GWTG), we compared the in-hospital use of different revascularization strategies (PCI versus CABG versus no revascularization) in diabetes mellitus patients with non-ST-segment-elevation myocardial infarction who had angiography, demonstrating multivessel coronary artery disease between July 2008 and December 2014. Factors associated with use of CABG versus PCI were identified using logistic multivariable regression analyses. A total of 29 769 patients from 539 hospitals were included in the study, of which 10 852 (36.4%) were treated with CABG, 13 760 (46.2%) were treated with PCI, and 5157 (17.3%) were treated without revascularization. The overall use of revascularization increased over the study period with an increase in the proportion undergoing PCI (45% to 48.9%; Ptrend=0.0002) and no change in the proportion undergoing CABG (36.1% to 34.7%; ptrend=0.88). There was significant variability between participating hospitals in the use of PCI and CABG (range: 22%-100%; 0%-78%, respectively; P value <0.0001 for both). Patient-level, but not hospital-level, characteristics were statistically associated with the use of PCI versus CABG, including anatomic severity of the disease, early treatment of adenosine diphosphate receptor antagonists at presentation, older age, female sex, and history of heart failure. Among patients with diabetes mellitus and multivessel coronary artery disease presenting with non-ST-segment-elevation myocardial infarction, only one third undergo CABG during the index admission. Furthermore, the use of PCI, but not CABG, increased modestly over the past 6 years.

Pandey A ，McGuire DK ，de Lemos JA ，Das SR ，Berry JD ，Brilakis ES ，Banerjee S ，Marso SP ，Barsness GW ，Simon DN ，Roe M ，Goyal A ，Kosiborod M ，Amsterdam EA ，Kumbhani DJ ... -  《Circulation-Cardiovascular Quality and Outcomes》

Bypass surgery after non-ST-segment elevation myocardial infarction better early than late?

Anderson JL ，Doty JR 《-》

Use of anticoagulant agents and risk of bleeding among patients admitted with myocardial infarction: a report from the NCDR ACTION Registry--GWTG (National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry--G

The aim of this study was to evaluate anticoagulant use patterns and bleeding risk in a contemporary population of patients with acute coronary syndrome. Current practice guidelines support the use of unfractionated heparin, low molecular weight heparin, bivalirudin, or fondaparinux in non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI). Little is known about how these agents are selected in clinical practice. Between January 2007 and June 2009, data were captured for 72,699 patients with NSTEMI and 48,943 patients with STEMI at 360 U.S. hospitals for the NCDR ACTION Registry-GWTG (National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines). Patients were categorized based on anticoagulant strategy selected during hospitalization and their CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of ACC/AHA [American College of Cardiology/American Heart Association] Guidelines) bleeding risk category. At least 1 anticoagulant was administered to 66,279 patients (91.2%) with NSTEMI and 46,149 patients (94.3%) with STEMI. Among STEMI patients, unfractionated heparin was most commonly used (66%), followed by bivalirudin (14%) and low molecular weight heparin (8%). In NSTEMI patients, unfractionated heparin was also the most commonly used anticoagulant (42%), followed by low molecular weight heparin (27%) and then bivalirudin (13%). There were significant differences in anticoagulant use by age, risk factors, concomitant medications, and invasive care. There was a 5-fold difference in the rate of bleeding between patients in the lowest and highest CRUSADE bleeding risk groups, which was consistently observed in most anticoagulant groups. There is a wide variability in the use of anticoagulant regimens with significant differences according to baseline characteristics and concomitant therapies. Major bleeding is common, though a great degree of the variability in the rate of bleeding is largely based on differences in baseline characteristics, comorbidities, and invasive treatment strategies, rather than specific anticoagulant regimens.

Kadakia MB ，Desai NR ，Alexander KP ，Chen AY ，Foody JM ，Cannon CP ，Wiviott SD ，Scirica BM ，National Cardiovascular Data Registry ... -  《-》

Utilization, Characteristics, and In-Hospital Outcomes of Coronary Artery Bypass Grafting in Patients With ST-Segment-Elevation Myocardial Infarction: Results From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcome

There are limited data on the utilization and outcomes of coronary artery bypass grafting (CABG) among ST-segment-elevation myocardial infarction (STEMI) patients in contemporary practice. Using data from National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines between 2007 and 2014, we analyzed trends in CABG utilization and hospital-level variation in CABG rates. Patients undergoing CABG during the index admission were categorized by the most common scenarios: (1) CABG only as the primary reperfusion strategy; (2) CABG after primary percutaneous coronary intervention; and (3) CABG after fibrinolytic therapy. A total of 15 145 patients (6.3% of the STEMI population) underwent CABG during the index hospitalization, with a decrease in utilization from 8.3% in 2007 to 5.4% in 2014 (trend P value <0.001). The hospital-level use of CABG in STEMI varied widely from 0.5% to 36.2% (median, 5.3%; interquartile range [IQR], 3.5%-7.8%; P value <0.001). Of all patients undergoing CABG, 45.8% underwent CABG only, 38.7% had CABG after percutaneous coronary intervention, and 8.2% CABG after fibrinolytic therapy. The median time intervals from cardiac catheterization/percutaneous coronary intervention to CABG were 23.3 hours (IQR, 3.0-70.3 hours) in CABG only, 49.7 hours (IQR, 3.2-70.3 hours) in CABG after percutaneous coronary intervention, and 56.6 hours (IQR, 22.7-96.0 hours) in CABG after fibrinolytic therapy. The Acute Coronary Treatment and Intervention Outcomes Network mortality risk scores differed modestly (median, 33; IQR, 28-40 versus median, 32; IQR, 27-38) between CABG and non-CABG patients. Patients undergoing CABG had similar in-hospital mortality rate (5.4% versus 5.1%) as those not treated with CABG. CABG is performed infrequently in STEMI patients during the index hospitalization, with rates declining in contemporary US practice over time. There was marked hospital-level variation in the use of CABG, and CABG was typically performed within 1 to 3 days after angiography. Observed mortality rates appear low, suggesting that CABG might be safely performed in select STEMI patients in a timely fashion.

Pi Y ，Roe MT ，Holmes DN ，Chiswell K ，Garvey JL ，Fonarow GC ，de Lemos JA ，Garratt KN ，Xian Y ... -  《Circulation-Cardiovascular Quality and Outcomes》