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ED Treatment Delays for Previous CABG Patients with STEMI

STONY BROOK, NY – There might be a good reason for it, but ST-segment elevation myocardial infarction (STEMI) patients who had previously undergone coronary artery bypass graft surgery were much less likely than other heart attack patients to be treated within the 90-minute recommended “door-to-balloon time.”

That was even the case when those patients were compared to a similar cohort with prior angioplasty, according to a study published in JACC: Cardiovascular Interventions.

The investigation led by Stony Brook University Hospital researchers was dubbed a “call to action” to increase response time for heart attack patients who had previously undergone CABG surgery.

The study used data from the National Cardiovascular Data Registry CathPCI Registry linked with the ACTION Registry-GWTG. With examination of records of 15,628 heart attack patients treated at 297 U.S. hospitals between June 2009 and September 2011, 6% were found to have had a history of previous coronary artery bypass graft surgery, 19% with previous angioplasty, and 75% with no prior history of procedures.

The STEMI patients who previously had revascularization through surgery were older, an average age of 66, than those with prior angioplasty, average age 60, or without any previous interventions, average age 59. They also were more likely to have other co-morbidities such as high blood pressure, high cholesterol, and diabetes.

Just 76% of patients with prior CABG surgery were treated within the recommended 90-minute door-to-balloon time, compared to 88.5% of patients with prior angioplasty and 88% of patients with no previous interventions.

More specifically, door-to-balloon time was achieved in 90% of patients with a history of angioplasty with a stent when the new lesion was located in the previous stent and in 87.3% of patients if the lesion was in a non-stented area. For patients with a history of CABG, 75.9 of those with the new lesion in the graft site and 77% of those with a lesion in a new vessel had their angioplasty done within 90 minutes.

Overall, patients who had been treated with CABG had a lower rate of successful procedures, 88.3%, as opposed 93.4% of patients who had a prior angioplasty and 94.4% of patients with no prior interventions. No significant differences in in-hospital mortality, major adverse events, and major bleeding were identified among the three groups, however.

Lead author Luis Gruberg, MD, FACC, of Stony Brook University, conceded that patients with a history of coronary artery bypass surgery have more complex anatomy and more comorbidities, adding in an American College of Cardiology press release, "Nonetheless, every effort should be made to improve timeliness in patients with a history of previous coronary artery bypass surgery.”

"Increased awareness of 'time is muscle,'" John S. Douglas Jr., MD, of Emory University School of Medicine in Atlanta, wrote in an accompanying editorial, "may lead to shortened door-to-cath lab times and timely performance for the more difficult patients.”

Douglas said the study "should be interpreted as a 'call to action' with the goal of earliest possible treatment in all heart attack patients, including those who have had prior coronary artery bypass graft surgery."

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