Department of Surgery, Duke University Medical Center, Durham, NC.
Department of Statistics, Duke Clinical Research Institute, 2400 Pratt St, Durham, NC.
Am Heart J. 2018 May;199:150-155. doi: 10.1016/j.ahj.2018.02.006. Epub 2018 Feb 11.
Perioperative myocardial infarction (MI) after coronary artery bypass graft surgery (CABG) has been associated with adverse outcome. Whether perioperative MI should be treated with dual antiplatelet therapy (DAPT) is unknown. We compared the effect of DAPT versus aspirin alone on short-term outcomes among patients with perioperative MI following CABG.
We used data from 3 clinical trials that enrolled patients undergoing isolated CABG: PREVENT IV (2002-2003), MEND-CABG II (2004-2005), and RED-CABG (2009-2010) (n = 9117). Perioperative MI was defined as CK-MB >5 times the upper limit of normal within 24 h of surgery (n = 2052). DAPT was defined as DAPT given after surgery and prior to discharge. A Cox regression model was used to assess the association between DAPT and 30-day nonfatal MI, stroke, or mortality after adjustment for baseline covariates.
DAPT (n = 527) and aspirin alone (n = 1525) cohorts were similar in baseline comorbidities. Off pump bypass was used in 5.2% (n = 106) of patients. There was no difference in the 30-day composite of death, MI or stroke between patients receiving DAPT versus aspirin alone, nor in any of the individual components. There were fewer all-cause re-hospitalizations at 30 days following surgery among patients in the DAPT group (adjusted HR 0.71, CI 0.52-0.97, P = .033).
One-quarter of CABG patients who had perioperative MI were treated with DAPT. DAPT was not associated with a difference in MI, stroke, or mortality at 30 days, but was associated with fewer re-hospitalizations. Further studies are needed to determine the optimal antiplatelet regimen following perioperative MI. What is already known about this subject? Perioperative myocardial infarction portends poor outcome but optimal management is currently unclear. While dual antiplatelet therapy is standard of care for acute coronary syndrome, its role in perioperative myocardial infarction is unknown. What does this study add? Dual antiplatelet therapy use during perioperative myocardial infarction was not associated with a difference in myocardial infarction, stroke or mortality at 30 days. It was, however, associated with fewer re-hospitalizations at 30 days. How might this impact on clinical practice? Dual antiplatelet therapy may be a potential treatment option for perioperative myocardial infarction after CABG surgery. Further studies are needed to better understand treatment for this disease process.
冠状动脉旁路移植术（CABG）后围手术期心肌梗死（MI）与不良结局相关。围手术期 MI 是否应采用双联抗血小板治疗（DAPT）尚不清楚。我们比较了 CABG 术后围手术期 MI 患者接受 DAPT 与单独使用阿司匹林治疗的短期结局。
我们使用了 3 项纳入接受单纯 CABG 患者的临床试验的数据：PREVENT IV（2002-2003 年）、MEND-CABG II（2004-2005 年）和 RED-CABG（2009-2010 年）（n=9117）。围手术期 MI 的定义为术后 24 小时内 CK-MB 升高至正常值上限的 5 倍以上（n=2052）。DAPT 定义为术后且在出院前给予的 DAPT。使用 Cox 回归模型，在校正基线协变量后评估 DAPT 与术后 30 天非致命性 MI、卒中和死亡率之间的关联。
DAPT（n=527）和单独使用阿司匹林（n=1525）两组患者的基线合并症相似。无复流的患者占 5.2%（n=106）。与单独使用阿司匹林相比，接受 DAPT 的患者在术后 30 天的死亡、MI 或卒中等复合终点方面没有差异，任何单一成分也没有差异。与单独使用阿司匹林相比，DAPT 组患者在术后 30 天内全因再住院的次数较少（校正 HR 0.71，CI 0.52-0.97，P=0.033）。
CABG 术后发生围手术期 MI 的患者中有四分之一接受了 DAPT 治疗。DAPT 治疗与 30 天的 MI、卒中和死亡率差异无统计学意义，但与再住院次数减少有关。需要进一步研究以确定围手术期 MI 后的最佳抗血小板治疗方案。
目前关于该主题的已知内容是什么？围手术期心肌梗死预示着预后不良，但目前其最佳治疗方法尚不清楚。虽然双联抗血小板治疗是急性冠状动脉综合征的标准治疗方法，但在围手术期心肌梗死中的作用尚不清楚。本研究有哪些新发现？在围手术期心肌梗死期间使用双联抗血小板治疗与 30 天的心肌梗死、卒中和死亡率无差异。然而，它与 30 天内的再住院次数减少有关。这对临床实践有何影响？DAPT 可能是 CABG 术后围手术期心肌梗死的一种潜在治疗选择。需要进一步研究以更好地了解该疾病过程的治疗方法。
