Prior CABG a surrogate for sicker patients

Patients with acute myocardial infarction who have had prior coronary artery bypass graft surgery have worse clinical outcome than those without prior CABG, a subanalysis of the VALIANT trial finds. Writing in the European Heart Journal, the UK researchers found that CABG patients were under-treated with some evidence-based secondary preventive therapy. Of the 14,703 patients with AMI complicated by heart failure, left ventricular dysfunction, or both enrolled in VALIANT (Valsartan in AMI Trial) 7% had a history of CABG. These patients were older, had more comorbidity and more frequent non-Q wave MI (66% vs 30%, p<0.0001) than those without prior CABG. At hospital presentation prior CABG patients were less likely to have received aspirin, a beta blocker, or thrombolytic therapy, but more likely to have received glycoprotein IIb/IIa inhibitor therapy, while rates of PCI were similar between patients with and without a history of CABG. Over 3 years of follow-up, unadjusted all-cause and cardiovascular mortality were higher among patients with prior CABG than those without (both p<0.001). After adjusting for over 25 significant pre-MI, qualifying MI, and post-MI baseline variables, history of CABG was an independent predictor of adverse cardiovascular outcomes, including the composite of cardiovascular death, MI, and heart failure (HR=1.29, p<0.0001). “Greater recognition is necessary for these high-risk patients, including optimization of evidence-based secondary preventive therapy,” the researchers concluded. An accompanying editorial said the findings confirm that “prior CABG is a surrogate for sicker patients and hence portends a poorer outcome.” Rather than producing guidelines tailored to patients with AMI in the setting of heart failure and prior CABG, “it simply needs to be mentioned that these are high-risk patients by definition,” the editorial said....