Thielmann M, Jakob H
Department of Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University Clinic of Essen, Germany.
Rocz Akad Med Bialymst. 2005;50:37-44.
The management and surgical revascularization treatment of patients with acute coronary syndromes (ACS) have undergone great evolution over the past decade. The objective of the present study was therefore to analyze the outcome and predictors of survival in patients unresponsive to maximal non-surgical treatment referred to emergency coronary artery bypass grafting (CABG) with ACS.
Between October 1999 and September 2004, a total of 3571 CABG patients underwent primary isolated CABG at our institution. Out of these, non-ACS (N-ACS) was present in 3124 patients (group 1), 386 patients (group 2) had non-ST-elevation ACS (NSTE-ACS), whereas 61 patients (group 3) had ST-elevation ACS (STE-ACS). Clinical data, in-hospital morbidity and mortality were prospectively recorded and studied retrospectively in the groups.
Left main stem stenosis was observed in 25%, 32%, and 41%, respectively (P<0.02). Previous myocardial infarction was found in 33%, 43%, and 73% (P<0.001). Overall in-hospital mortality was 1.5% in group 1, 4.2% in group 2, and 13.0% in group 3 (P< 0.001). Logistic regression and receiver operating characteristic analyses identified cTnI as the strongest preoperative predictor significantly related to in-hospital mortality. A preoperative cTnI level above 1.5 ng/ml was the best single predictor for in-hospital mortality amongst patients with ACS.
The present study clearly demonstrates a significant difference of in-hospital morbidity and mortality between patients with ACS undergoing CABG. A more precise patient's risk stratification on admission and improvements in the perioperative management with adjunctive pharmacological therapies and the use of intraaortic balloon counter pulsation may improve patients' outcome.
在过去十年中，急性冠状动脉综合征（ACS）患者的管理和手术血运重建治疗发生了巨大的演变。因此，本研究的目的是分析那些对最大程度的非手术治疗无反应而接受急诊冠状动脉旁路移植术（CABG）的ACS患者的生存结局及预测因素。
1999年10月至2004年9月期间，共有3571例CABG患者在我们机构接受了初次单纯CABG手术。其中，3124例患者（第1组）为非ACS患者，386例患者（第2组）患有非ST段抬高型ACS（NSTE-ACS），而61例患者（第3组）患有ST段抬高型ACS（STE-ACS）。对这些组的临床数据、住院期间的发病率和死亡率进行了前瞻性记录并进行回顾性研究。
左主干狭窄分别在第1组、第2组和第3组中观察到25%、32%和41%（P<0.02）。既往心肌梗死在第1组、第2组和第3组中分别为33%、43%和73%（P<0.001）。第1组的总体住院死亡率为1.5%，第2组为4.2%，第3组为13.0%（P<0.001）。逻辑回归和受试者工作特征分析确定肌钙蛋白I（cTnI）是与住院死亡率显著相关的最强术前预测因素。术前cTnI水平高于1.5 ng/ml是ACS患者住院死亡率的最佳单一预测因素。
本研究清楚地表明，接受CABG的ACS患者在住院发病率和死亡率方面存在显著差异。入院时更精确的患者风险分层以及通过辅助药物治疗和使用主动脉内球囊反搏改善围手术期管理可能会改善患者的结局。
