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      Clinical Characteristics and Outcomes of Patients with Acute Coronary Syndrome and Prior Coronary Artery Bypass Grafting in a Large Middle Eastern Cohort

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          Abstract

          Background:

          Acute Coronary Syndrome (ACS) can occur in patients with prior coronary artery bypass grafting (CABG). In the Gulf Registry of acute coronary events (Gulf RACE), we identified the clinical characteristics and in-hospital outcomes of these patients.

          Methods:

          Clinical characteristics and in-hospital outcomes for 461 ACS patients with prior CABG are compared to 7715 ACS patients without prior CABG enrolled from 64 hospitals in 6 Gulf countries over a 6-month period.

          Results:

          The overall incidence of ACS with prior CABG was 5.6% out of 8176 patients. The ACS with prior CABG were older (63 vs 55 years, P<0.0001), had more history of diabetes (62.3 vs 37.6%, P <0.0001), dyslipidemia (70.3 vs 29.5%, P<0.0001), and hypertension (75.7 vs 47.8%, P<0.0001) compared with the non-CABG group. They presented more frequently with dyspnea (14.8 vs 9.5%, P<0.0005), non-ST segment elevation myocardial infarction (41.4 vs 31.6%, P<0.0001) and echocardiographic evidence of left ventricular dysfunction (49.4 vs 29.8%, P<0.0001) than ACS without prior CABG. They had a complicated in-hospital course with more recurrent ischemia (13.9 vs 9.3%, P=0.0011), heart failure (24.1 vs 15.7%), and stroke (2.2 vs 0.6%) compared with those without CABG. The in-hospital mortality rate was 5.6% in the CABG group compared with 3.5% in the ACS without prior CABG group. After adjusting for confounders, prior CABG was independently associated with recurrent ischemia and shock, more in patients presenting with ST elevation than non-ST elevation ACS.

          Conclusions:

          Patients with ACS and prior CABG are a high-risk group with poor outcomes irrespective of their older age and comorbidities. They should be identified and treated differently to improve their outcomes.

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          Most cited references 23

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          Predictors of hospital mortality in the global registry of acute coronary events.

          Management of acute coronary syndromes (ACS) should be guided by an estimate of patient risk. To develop a simple model to assess the risk for in-hospital mortality for the entire spectrum of ACS treated in general clinical practice. A multivariable logistic regression model was developed using 11 389 patients (including 509 in-hospital deaths) with ACS with and without ST-segment elevation enrolled in the Global Registry of Acute Coronary Events (GRACE) from April 1, 1999, through March 31, 2001. Validation data sets included a subsequent cohort of 3972 patients enrolled in GRACE and 12 142 in the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial. The following 8 independent risk factors accounted for 89.9% of the prognostic information: age (odds ratio [OR], 1.7 per 10 years), Killip class (OR, 2.0 per class), systolic blood pressure (OR, 1.4 per 20-mm Hg decrease), ST-segment deviation (OR, 2.4), cardiac arrest during presentation (OR, 4.3), serum creatinine level (OR, 1.2 per 1-mg/dL [88.4- micro mol/L] increase), positive initial cardiac enzyme findings (OR, 1.6), and heart rate (OR, 1.3 per 30-beat/min increase). The discrimination ability of the simplified model was excellent with c statistics of 0.83 in the derived database, 0.84 in the confirmation GRACE data set, and 0.79 in the GUSTO-IIb database. Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.
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            Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study.

            This study defined long-term patency of saphenous vein grafts (SVG) and internal mammary artery (IMA) grafts. This VA Cooperative Studies Trial defined 10-year SVG patency in 1,074 patients and left IMA patency in 457 patients undergoing coronary artery bypass grafting (CABG). Patients underwent cardiac catheterizations at 1 week and 1, 3, 6, and 10 years after CABG. Patency at 10 years was 61% for SVGs compared with 85% for IMA grafts (p 2.0 mm in diameter SVG patency was 88% versus 55% in vessels 2.0 mm in diameter.
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              Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock.

              Early mechanical revascularization in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock is a therapeutic strategy that reduces mortality. It has been a class I recommendation in guidelines from the American College of Cardiology and the American Heart Association since 1999 for patients younger than 75 years. However, little is known about implementation of these guidelines in practice. To assess trends in early revascularization and mortality for patients with cardiogenic shock complicating AMI and to determine whether the national guidelines affect revascularization rates. Prospective, observational study of 293,633 patients with ST-elevation myocardial infarction (25,311 [8.6%] had cardiogenic shock; 7356 [29%] had cardiogenic shock at hospital presentation) enrolled in the National Registry of Myocardial Infarction (NRMI) from January 1995 to May 2004 at 775 US hospitals with revascularization capability (defined as the capability to perform cardiac catheterization, percutaneous coronary intervention [PCI], and open-heart surgery). Management patterns and in-hospital mortality rates. There was an increase in primary PCI rates from 27.4% to 54.4% (P<.001) in hospitals with revascularization capability that paralleled the change in PCI for ST-elevation myocardial infarction. There was no significant change in rates of immediate coronary artery bypass graft surgery (from 2.1% to 3.2%). Propensity-adjusted multivariable analyses demonstrated that primary PCI was associated with a decreased odds of death during hospitalization (odds ratio, 0.46; 95% confidence interval, 0.40-0.53). There were no differences in the rates of change in revascularization rates based on the date when the guidelines were released regardless of patient age. Overall in-hospital cardiogenic shock mortality decreased from 60.3% in 1995 to 47.9% in 2004 (P<.001). The use of PCI for patients with cardiogenic shock was associated with improved survival in a large group of hospitals with revascularization capability. The American College of Cardiology and American Heart Association guidelines had no detectable temporal impact on revascularization rates. These findings support the need for increased adherence to these guidelines.
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                Author and article information

                Journal
                Open Cardiovasc Med J
                TOCMJ
                The Open Cardiovascular Medicine Journal
                Bentham Open
                1874-1924
                30 August 2011
                2011
                : 5
                : 196-202
                Affiliations
                [1 ]Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait
                [2 ]Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates and Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, USA
                [3 ]Department of Cardiac Surgery, Chest Diseases Hospital, Ministry of Health, Kuwait
                [4 ]Division of Cardiology, Department of Medicine, Adan Hospital, Ministry of Health, Kuwait
                [5 ]Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
                [6 ]Royal Hospital, Muscat, Oman
                [7 ]Department of Non-communicable Diseases Control, Ministry of Health, Muscat, Oman
                [8 ]Mohammed Bin Khalifa Cardiac Centre, Manama, Bahrain
                [9 ]Hamad General Hospital and Hamad Medical Corporation, Doha, Qatar
                [10 ]Department of Medicine, Faculty of Medicine, Sana'a University, Sana'a, Yemen
                Author notes
                [* ]Address correspondence to this author at the Faculty of Medicine – Kuwait University, Medicine Department – Forth floor P.O. Box 24923 - Safat 13110 Kuwait; Tel: (965) 24986353; Fax: (965) 25318454; E-mail: muath.alanbaei@ 123456hsc.edu.kw
                Article
                TOCMJ-5-196
                10.2174/1874192401105010196
                3170976
                21915225
                © Alanbaei et al.; Licensee Bentham Open.

                This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

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