Koronarchirurgie im akuten Koronarsyndrom

Welche prognostischen Faktoren bleiben?
  • Konstantin Alexiou
  • M. Wilbring
  • U. Kappert
  • A. Staroske
  • D. Joskowiak
  • K. Matschke
  • S. M. Tugtekin
Originalarbeiten

Zusammenfasung

Hintergrund:

Im Rahmen einer retrospektiven Studie wurde analysiert, inwieweit Patienten im akuten Koronarsyndrom (ACS) von einer chirurgischen Therapie profitieren.

Patienten und Methoden:

Zwischen Januar 2003 und Mai 2005 unterzogen sich im Herzzentrum Dresden 3127 Patienten einer isolierten koronaren Bypassoperation. 220 dieser Patienten befanden sich im ACS; 88 Patienten hiervon im Stadium der instabilen Angina pectoris (IAP) (Gruppe I), 97 Patienten ohne ST-Elevationsinfarkt (NSTEMI) (Gruppe II) und 35 Patienten mit ST-Elevationsinfarkt (STEMI) (Gruppe III).

Ergebnisse:

Die durchschnittliche Gesamtsterblichkeit lag bei 6,4 % (n = 14); 2,2 % innerhalb der Gruppe I, 9,2 % in Gruppe II und 8,5 % in Gruppe III. Die logistische Regressionsanalyse ergab folgende signifikante Mortalitätsfaktoren: Alter, NYHA, EF, Katecholamine, kardiogener Schock, Rhythmusstörungen, COPD, Niereninsuffizienz, und EuroSCORE (p < 0.0001). Die Zeit zwischen Symptomauftritt und Operation war in Gruppe III bei Überlebenden (5,1 ± 2,7 h) und Verstorbenen (11,4 ± 3,2 h) signifikant unterschiedlich (p < 0.0007). Präoperatives TnT zeigte keine prognostische Relevanz.

Fazit:

Die koronarchirurgische Therapie im ACS kann mit akzeptablen Ergebnissen durchgeführt werden, wobei das klinische Ergebnis in den einzelnen Gruppen unterschiedlich ist und zwingend eine individuelle Risikostratifikation notwendig macht. Prognostisch scheint insbesondere in der STEMIGruppe eine frühe Revaskularisation bedeutend zu sein.

Schlüsselwörter

akutes Koronarsyndrom Bypassoperation STEMI Mortalitätsprädiktoren EuroSCORE 

CABG in acute coronary syndrome – prognostic factors

Abstract

Background:

The objective of the present study was to analyze the outcome and predictors of in-hospital mortality in patients (pts) referred to CABG with acute coronary syndrome (ACS).

Patients and methods:

Between January 2003 and May 2005, a total of 3127 pts underwent primary isolated CABG at our institution, including 220 pts with ACS. UAP was present in 88 pts (group I), 97 pts (group II) had NSTEMI, whereas 35 pts (group III) had STEMI. Clinical data, inhospital mortality was studied, retrospectively.

Results:

Overall in-hospital mortality was 6.4 % (n = 14), being 2.2 % in group I (n = 2), 9.2 % in group II (n = 9) and 8.5 % (n = 3) in group III (p < 0.05). Logistic regression identified age, NYHA, EF, catecholamine support, cardiogenic shock, COPD, renal disease and EuroSCORE (p < 0.0001) as significant predictors related to in-hospital mortality. The mean time from the onset of symptoms to revascularization differed significantly between survivors (5.1 ± 2.7 h) and no survivors (11.4 ± 3.2 h) (p < 0.0007) in the STEMI group. Preoperative cTnI did not provide any prognostic information.

Conclusion:

CABG in pts with ACS can be performed with good clinical results. The clinical outcome is dependent on the ACS group. Therefore an individual risk stratification of each pt in ACS is necessary. The time interval of 6 h seems to be crucial as a prognostic variable in the STEMI group.

Keywords

acute coronary syndrome coronary artery bypass grafting STEMI predictors of mortality EuroSCORE 

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Literatur

  1. 1.
    Boden WE (2002) Is it time to reassess the optimal timing of coronary artery bypass graft surgery following acute myocardial infarction? Am J Cardiol 90:35–38CrossRefGoogle Scholar
  2. 2.
    Boden WE, O’Rourke RA, Crawford MH et al (1998) Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Qwave Infarction Strategies in Hospital (VANQWISH) trial Investigators. N Engl J Med 338:1785–1792PubMedCrossRefGoogle Scholar
  3. 3.
    Cannon CP, Weintraub WS, Demopoulos LA et al for the TACTICS investigators (2001) Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 344:1879–1887PubMedCrossRefGoogle Scholar
  4. 4.
    Cesena FH, Favarato D, Cesar LA, de Oliveira SA, da Luz PL (2004) Cardiac complications during waiting for elective coronary artery bypass graft surgery: incidence, temporal distribution and predictive factors. Eur J Cardiothorac Surg 25:196–202PubMedCrossRefGoogle Scholar
  5. 5.
    Coleman WS, DeWood MA, Berg Jr R, Selinger SL, Leonard JJ, Siwek LG (1995) Surgical intervention in acute myocardial infarction: an historical perspective. Semin Thorac Cardiovasc Surg 7:176–83PubMedGoogle Scholar
  6. 6.
    FRISC II investigators (1999) Invasive compared with non-invasive treatment in unstable coronaryartery disease: FRISC II prospective randomised multicentre study. Fragmin and Fast Revascularisation during In-Stability in Coronary artery disease Investigators. Lancet 354:708–715Google Scholar
  7. 7.
    Goldberg RJ, Currie K, White K, Brieger D, Steg PG, Goodman SG, Dabbous O, Fox KA, Gore JM (2004) Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (The Global Registry of Acute Coronary Events [GRACE]). Am J Cardiol 93:288–293PubMedCrossRefGoogle Scholar
  8. 8.
    Gunn J, Taggart DP (2003). Revascularisation for acute coronary syndromes: PCI or CABG? Heart 89:967–970PubMedCrossRefGoogle Scholar
  9. 9.
    Hamm C, Arntz HR, Bode C et al (2004) Leitlinien Akutes Koronarsyndrom Teil 1: Akutes Koronarsyndrom ohne ST-Hebung. Clin Res Cardiol 93:72–90Google Scholar
  10. 10.
    Hamm C et al (2004) Leitlinien Akutes Koronarsyndrom Teil 2: Akutes Koronarsyndrom mit ST-Hebung. Clin Res Cardiol 93:324–341Google Scholar
  11. 11.
    Hasdai D, Behar S, Wallentin L, Danchin N, Gitt AK, Boersma E, Fioretti PM, Simoons ML, Battler A (2002) A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin. The Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J 23:1190–1201PubMedCrossRefGoogle Scholar
  12. 12.
    Higgins TL, Estefanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L (1992) Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score. JAMA 267:2344–2348PubMedCrossRefGoogle Scholar
  13. 13.
    Lee DC, Oz MC, Weinberg AD, Lin SX, Ting W (2001) Optimal timing of revascularization: transmural versus nontransmural acute myocardial infarction. Ann Thorac Surg 71:1197–1202PubMedCrossRefGoogle Scholar
  14. 14.
    Möckel M, Müller R, Vollert JO, Müller C, Danne O, Gareis R, Störk T, Dietz R, Koenig W (2007) Lipoprotein- associated phospholipase A(2) for early risk stratification in patients with suspected acute coronary syndrome: a multi-marker approach : The North Wuerttemberg and Berlin Infarction Study-II (NOBIS-II) Clin Res Cardiol;96:604–612PubMedCrossRefGoogle Scholar
  15. 15.
    Rogers WJ, Canto JG, Lambrew CT, Tiefenbrunn AJ, Kinkaid B, Shoultz DA, Frederick PD, Every N (2000) Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the US from 1990 through 1999: the National Registry of Myocardial Infarction 1, 2 and 3. J Am Coll Cardiol 36:2056–2063PubMedCrossRefGoogle Scholar
  16. 16.
    Roques F, Nashef SAM, Gauducheau ME, et al (1999) Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 10030 patients. Eur J Cardiothorac Surg 15:816–823PubMedCrossRefGoogle Scholar
  17. 17.
    Rosenkranz S, Maier LS, Maack C, Böhm M (2007) Hotline update of clinical trials and registries presented at the German cardiac society meeting 2007 Clin Res Cardiol 96:457–468PubMedCrossRefGoogle Scholar
  18. 18.
    Selinger SL, Berg Jr R, Leonard JJ, Coleman WS, DeWood MA (1984) Surgical Intervention in Acute Myocardial Infarction Texas Heart Institute 11:44–51Google Scholar
  19. 19.
    Terkelsen CJ, Lassen JF, Norgaard BL, Gerdes JC, Jensen T, Gotzsche LB, Nielsen TT, Andersen HR (2005) Mortality rates in patients with ST-elevation vs. non-ST-elevation acute myocardial infarction: observations from an unselected cohort. Eur Heart J. 26(1):18–26PubMedCrossRefGoogle Scholar
  20. 20.
    The Joint European Society of Cardiology/American College of Cardiology Committee (2000). Myocardial infarction redefined – a consensus document of The Joint European Society of Cardiology/ American College of Cardiology Committee for the Redefinition of Myocardial Infarction. Eur Heart J 21:1502–1513Google Scholar
  21. 21.
    Thielmann M, Massoudy P, Neuhäuser M, Knipp S, Kamler M, Piotrowski J, Mann K, Jakob H (2005) Prognostic value of preoperative cardiac troponin I in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery. Chest 128:3526–3536PubMedCrossRefGoogle Scholar
  22. 22.
    Thielmann M, Massoudy P, Neuhäuser M, Tsagakis K, Marggraf G, Kamler M, Mann K, Erbel R, Jakob H (2006) Prognostic value of preoperative cardiac troponin I in patients undergoing coronary artery bypass surgery with non-ST-segment elevation or ST-elevation acute coronary syndromes. Circulation 114[suppl I]:I-448–I-453CrossRefGoogle Scholar
  23. 23.
    Tugtekin SM, Alexiou K, Kappert U, Esche H, Joskowiak D, Knaut M, Matschke K (2006) Coronary reoperation with and without cardiopulmonary bypass Clin Res Cardiol 95:93–98PubMedCrossRefGoogle Scholar
  24. 24.
    Voisine P, Mathieu P, Doyle D, Perron J, Baillot R, Raymond G, Metras J, Dagenais F (2006) Influence of time elapsed between myocardial infarction and coronary artery bypass grafting surgery on operative mortality. Eur J Cardiothoracic Surg 29:319–323CrossRefGoogle Scholar
  25. 25.
    Weiss JL, Marino PN, Shapiro EP (1991) Myocardial infarct expansion: recognition, significance and pathology. Am J Cardiol 68:35D–40DPubMedCrossRefGoogle Scholar

Copyright information

© Spinger 2008

Authors and Affiliations

  • Konstantin Alexiou
    • 1
    • 2
  • M. Wilbring
    • 1
  • U. Kappert
    • 1
  • A. Staroske
    • 1
  • D. Joskowiak
    • 1
  • K. Matschke
    • 1
  • S. M. Tugtekin
    • 1
  1. 1.HerzzentrumUniversität DresdenDresdenBRD
  2. 2.Herzzentrum DresdenUniversitätsklinikDresdenBRD

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