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      Definitions of post-coronary artery bypass grafting myocardial infarction: variations in incidence and prognostic significance

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          Abstract

          OBJECTIVES

          Using data from the CORONARY trial ( n = 4752), we evaluated the incidence and prognostic significance of myocardial infarction (MI) applying different definitions based on peak postoperative creatine kinase-MB isoenzyme and cardiac troponin levels. We then aimed to identify the peak cardiac troponin during the first 3 postoperative days that was independently associated with a 2-fold increase in 30-day mortality.

          METHODS

          To combine different assays, we analysed cardiac troponins in multiples of their respective upper limit of normal (ULN). We identified the lowest threshold with a hazard ratio (HR) >2 for 30-day mortality independent of EuroSCORE and on- versus off-pump surgery.

          RESULTS

          Depending on the definition used based on creatine kinase-MB, the incidence of MI after coronary artery bypass grafting (CABG) ranged from 0.6% to 19% and the associated HRs for 30-day mortality ranged from 2.7 to 6.9. Using cardiac troponin (1528 patients), the incidence of MI ranged from 1.7% to 13% depending on the definition used with HRs for 30-day mortality ranging from 5.1 to 7.2. The first cardiac troponin threshold we evaluated, 180xULN, was associated with an adjusted HR for 30-day mortality of 7.6 [95% confidence interval (CI) 3.4–17.1] when compared to <130xULN. The next independent threshold was 130xULN with an adjusted HR for 30-day mortality of 7.8 (95% CI 2.3–26.1). The next cardiac troponin tested threshold (70xULN) did not meet criteria for significance.

          CONCLUSIONS

          Our results illustrate that the incidence and prognosis of a post-CABG MI varies based on the definition used. Validated post-CABG MI diagnostic criteria formulated from their independent association with important clinical outcomes are needed.

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          Most cited references 11

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          Universal definition of myocardial infarction.

           S Alpert,  Brian White,   (2007)
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            Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.

            Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.
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              Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year.

              Previously, we reported that there was no significant difference at 30 days in the rate of a primary composite outcome of death, myocardial infarction, stroke, or new renal failure requiring dialysis between patients who underwent coronary-artery bypass grafting (CABG) performed with a beating-heart technique (off-pump) and those who underwent CABG performed with cardiopulmonary bypass (on-pump). We now report results on quality of life and cognitive function and on clinical outcomes at 1 year. We enrolled 4752 patients with coronary artery disease who were scheduled to undergo CABG and randomly assigned them to undergo the procedure off-pump or on-pump. Patients were enrolled at 79 centers in 19 countries. We assessed quality of life and cognitive function at discharge, at 30 days, and at 1 year and clinical outcomes at 1 year. At 1 year, there was no significant difference in the rate of the primary composite outcome between off-pump and on-pump CABG (12.1% and 13.3%, respectively; hazard ratio with off-pump CABG, 0.91; 95% confidence interval [CI], 0.77 to 1.07; P=0.24). The rate of the primary outcome was also similar in the two groups in the period between 31 days and 1 year (hazard ratio, 0.79; 95% CI, 0.55 to 1.13; P=0.19). The rate of repeat coronary revascularization at 1 year was 1.4% in the off-pump group and 0.8% in the on-pump group (hazard ratio, 1.66; 95% CI, 0.95 to 2.89; P=0.07). There were no significant differences between the two groups at 1 year in measures of quality of life or neurocognitive function. At 1 year after CABG, there was no significant difference between off-pump and on-pump CABG with respect to the primary composite outcome, the rate of repeat coronary revascularization, quality of life, or neurocognitive function. (Funded by the Canadian Institutes of Health Research; CORONARY ClinicalTrials.gov number, NCT00463294.).
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                Author and article information

                Journal
                Eur J Cardiothorac Surg
                Eur J Cardiothorac Surg
                ejcts
                European Journal of Cardio-Thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery
                Oxford University Press
                1010-7940
                1873-734X
                January 2020
                10 June 2019
                01 January 2021
                : 57
                : 1
                : 168-175
                Affiliations
                [1 ] Department of Health Research Methods, Evidence and Impact, McMaster University , Hamilton, ON, Canada
                [2 ] Department of Medicine, McMaster University, Hamilton , ON, Canada
                [3 ] Population Health Research Institute , Hamilton, ON, Canada
                [4 ] Department of Surgery, McMaster University , Hamilton, ON, Canada
                [5 ] Department of Pathology and Molecular Medicine, McMaster University , Hamilton, ON, Canada
                [6 ] Department of Medicine, Université de Sherbrooke , Sherbrooke, QC, Canada
                [7 ] Cardiothoracic Department, Aristotle University of Thessaloniki , Thessaloniki, Greece
                Author notes
                Corresponding author. Department of Surgery, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada. Tel: +1-905-5274322 (ext. 40306); fax: +1-905-5778017; e-mail: richard.whitlock@ 123456phri.ca (R.P.Whitlock).
                Article
                PMC6908926 PMC6908926 6908926 ezz161
                10.1093/ejcts/ezz161
                6908926
                31180497
                © The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

                This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

                Page count
                Pages: 8
                Funding
                Funded by: Canadian Institutes of Health Research 10.13039/501100000024
                Funded by: Canada Research Chairs 10.13039/501100001804
                Categories
                Myocardial Revascularization
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