CABG for ACS: The European Experience
Abstract & Commentary
With Comments by Michael H. Crawford, MD, Professor of Medicine, Chief of Clinical Cardiology, University of California, San Francisco, Editor, Clinical Cardiology Alert.
Synopsis: The in-hospital outcomes of CABG patients were equivalent to non-CABG patients, suggesting that CABG remains a viable alternative to PCI in selected patients with ACS.
Source: Solodky A, et.al. Cardiology. 2005;103:44-47.
It is generally believed that coronary artery bypass graft (CABG) surgery is the least desirable course of action in hospitalized patients with acute coronary syndromes (ACS) because outcomes would not be as good as with elective surgery. Older trials such as VANQWISH support this view, but there is little contemporary data. Thus, this report from the Euro Heart Survey ACS is of interest. During a 9-month period starting in 2000, over 10,000 patients with ACS admitted to hospitals with and without catheterization laboratories and coronary surgery capabilities were enrolled from across Europe. The initial ECG categorized patients into 3 groups: ACS with ST elevation; without ST elevation; and an indeterminate ECG. These 3 groups were then subdivided into those that had CABG in hospital or did not. Final discharge diagnosis was also assessed.
Results: Overall, 4.5% of the ACS patients had CABG during their hospitalization; more commonly non-ST elevation patients (5.4%) and least commonly ST elevation patients (3.4%). Also, patients with the discharge diagnosis of unstable angina more likely had CABG (6.6%) than those with Q (2.4%) or non-Q myocardial infarction (MI) (3.8%). Overall, CABG patients were more likely to be men, diabetics, and had prior angina and 3-vessel disease (P < .01). CABG patients were less likely to have had thrombolysis or percutaneous coronary interventions (PCI). Although, 15% of the CABG patients also had PCI while in hospital. Of interest, only 50% of the non-CABG patients had cardiac catheterization. Mortality in hospital was 3.7% for CABG patients and 4.8% for non-CABG patients (P = NS), and there were no subgroups who did better or worse with CABG. Solodky and colleagues concluded that the in-hospital outcomes of CABG patients were equivalent to non CABG patients, suggesting that CABG remains a viable alternative to PCI in selected patients with ACS.
Comments
This study shows that CABG remains an unpopular choice for therapy in ACS. Even by 1 month of admission, only 9.6% had undergone CABG. This is similar to the findings in other studies such as PURSUIT in which 11.5% of non-ST elevation ACS patients went for CABG within 30 days with a mortality of 4.8% in 30 days, suggesting that European practice is similar to that in North America. However, this may be deceptive because in the large majority of Euro Heart Survey ACS patients who did not have CABG, the cardiac catheterization rate was about 50%. In PURSUIT, about two-thirds underwent catheterization. Since many of the European hospitals in this study did not have catheterization labs, the rate of CABG may be underrepresented.
It was encouraging that the mortality rate was low with CABG (3.5%) and equivalent to non-CABG. This is much lower than the CABG mortality observed in VANQWISH, which contributed to the lack of benefit for a revascularization strategy in that study of non-ST elevation MI. Thus, CABG is a reasonable alternative for patients with ACS in whom PCI is likely to be ineffective or has failed.
The in-hospital outcomes of CABG patients were equivalent to non-CABG patients, suggesting that CABG remains a viable alternative to PCI in selected patients with ACS.
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