Circulation, Vol 82, 903-912, Copyright © 1990 by American Heart Association
T Force, P Hibberd, G Weeks, AJ Kemper, P Bloomfield, D Tow, M Josa, S Khuri and AF Parisi
The clinical significance of perioperative myocardial infarction (MI) after
coronary artery bypass surgery is not known. Therefore, strategies for the
risk stratification of these patients do not exist. This study was
undertaken to define the effect of perioperative MI on prognosis after
discharge from the hospital and to develop an approach to the risk
stratification of these patients. Fifty-nine patients with and 115 patients
without perioperative MI were observed for 30 months for the development of
cardiac events (death, nonfatal MI, and admission to hospital for unstable
angina or congestive heart failure). Patients with perioperative MI were
significantly more likely than patients without to have a cardiac event
(31% versus 12%, p less than 0.01) and multiple events (19% versus 1%, p
less than 0.001). Cox regression analysis identified two independent
predictors of cardiac events other than perioperative MI (relative risk,
2.7): inadequate revascularization (relative risk, 3.5) and depressed (less
than 40%) postoperative ejection fraction (EF) (relative risk, 2.1).
Event-free survival rate of patients with perioperative MI varied markedly
depending on the number of other negative prognostic variables present.
Patients with perioperative MI who were adequately revascularized and had a
postoperative EF greater than 40% had an event-free survival rate similar
to patients without a perioperative MI (92% versus 87%, p = NS). Patients
with perioperative MI who were inadequately revascularized and had
depressed postoperative EF had an event-free survival rate of 13% (p less
than 0.001 versus all other subsets). Event-free survival rate was
intermediate (68%) in patients with perioperative MI and with only one of
the other two variables (p less than 0.001 versus other subsets). In
conclusion, perioperative MI adversely affects prognosis. Patients can be
stratified into low, high, and intermediate risk subsets based on a simple
assessment of the adequacy of revascularization and a determination of
residual left ventricular function.
ARTICLES
Perioperative myocardial infarction after coronary artery bypass surgery. Clinical significance and approach to risk stratification
Department of Medicine, Brockton-West Roxbury Veterans Administration Medical Center, Boston, MA.
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