Department of Cardiology, Rambam Health Care Campus and the Technion-Israel Institute of Technology, Haifa, Israel.
JACC Cardiovasc Interv. 2012 Sep;5(9):919-26. doi: 10.1016/j.jcin.2012.06.009.
This study sought to assess the contemporary outcomes of patients with prior coronary artery bypass graft (CABG) who present with moderate and high-risk acute coronary syndromes (ACS) and are treated with an early invasive strategy and contemporary antithrombin regimens.
The prognosis of patients with ACS and prior CABG in relation to triage strategy and contemporary antithrombotic regimens is unknown.
In the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 2,475 of 13,764 patients (18.0%) with ACS managed with an early invasive strategy had previously undergone CABG. Their outcomes were examined according to treatment and randomized antithrombin regimen.
Prior CABG was associated with older age, more frequent comorbidities, higher Thrombolysis In Myocardial Infarction risk score, and lower left ventricular ejection fraction. Patients with versus without prior CABG were less likely to undergo (repeat) CABG and were more likely to be managed medically. At 1 year, patients with versus without prior CABG had higher rates of major adverse cardiac events (MACE) (22.5% vs. 15.2%, p < 0.0001) due to greater mortality (5.4% vs. 3.9%, p < 0.0001), myocardial infarction (10.0% vs. 6.8%, p < 0.0001), and unplanned revascularization (13.1% vs. 8.2%, p < 0.0001). History of CABG was an independent predictor of MACE. The 1-year MACE rates were not significantly different after randomization to bivalirudin versus heparin plus a glycoprotein IIb/IIIa inhibitor (odds ratio: 1.24, 95% confidence interval: 0.90 to 1.70).
Despite the progress in the treatment of coronary artery disease, patients with prior CABG and ACS have a poor prognosis, substantially worse than for those without prior CABG. Whereas bivalirudin monotherapy was an acceptable treatment for these patients, it did not improve their prognoses.
本研究旨在评估既往行冠状动脉旁路移植术（CABG）且伴有中高危急性冠状动脉综合征（ACS）的患者采用早期侵入性策略和当代抗凝方案的治疗效果。
目前尚不清楚 ACS 合并既往 CABG 患者的预后与分诊策略和当代抗血栓形成方案之间的关系。
在 ACUITY（急性导管插入术和紧急介入治疗策略）试验中，13764 例 ACS 患者（18.0%）接受了早期侵入性策略治疗，其中 2475 例患者有既往 CABG 病史。根据治疗和随机抗凝方案，对他们的结局进行了检查。
既往 CABG 与年龄较大、更常见的合并症、较高的溶栓治疗心肌梗死风险评分和较低的左心室射血分数有关。与无既往 CABG 病史的患者相比，有既往 CABG 病史的患者更不可能接受（再次）CABG 手术，而更有可能接受药物治疗。1 年后，与无既往 CABG 病史的患者相比，有既往 CABG 病史的患者的主要不良心脏事件（MACE）发生率更高（22.5% vs. 15.2%，p < 0.0001），这主要是由于死亡率更高（5.4% vs. 3.9%，p < 0.0001）、心肌梗死（10.0% vs. 6.8%，p < 0.0001）和非计划血运重建（13.1% vs. 8.2%，p < 0.0001）。既往 CABG 病史是 MACE 的独立预测因子。与随机分组至比伐卢定组和肝素加糖蛋白 IIb/IIIa 抑制剂组相比，1 年后的 MACE 发生率无显著差异（比值比：1.24，95%置信区间：0.90 至 1.70）。
尽管在治疗冠状动脉疾病方面取得了进展，但既往 CABG 合并 ACS 的患者预后仍较差，明显差于无既往 CABG 病史的患者。虽然比伐卢定单药治疗是这些患者可接受的治疗方法，但并未改善其预后。
