Rethinking Surgical NSTEMI Treatment

Objectives: For patients with a non-ST segment elevation myocardial infarction (NSTEMI), guideline recommendations regularly fall short in regard to adequate risk-assessed time management until coronary artery bypass surgery (CABG). Overall, 5 to 10% of all NSTEMI patients ultimately require revascularization surgery, with guidelines suggesting an individual approach especially in nonemergent NSTEMI patients. Considering these cohorts high-risk characteristics, a more patient-tailored and risk-stratified approach is crucial. As such, this study aimed to investigate the risk-assessed optimal timing from NSTEMI onset until CABG in NSTEMI patients.

Methods: We conducted a comprehensive single-center, retrospective, observational study of 485 NSTEMI patients undergoing isolated CABG between 2016 and 2020. Our study cohort was divided into three groups by time from NSTEMI onset until surgical revascularization; group 1 (<48 h, n = 138); group 2 (48–72 h, n = 205), and group 3 (>7 d, n = 155). Investigated were in-hospital morbidity and mortality.

Result: Overall, group 1 had considerably more critical patients (elevated cardiac markers (p = 0.001), cardiogenic shock (p < 0.001), intubation (p = 0.006), left main disease (LMD) (p = 0.012), and reduced left ventricular function (LVEF) (p = 0.063) resulting in a higher EuroSCORE II (p = 0.001). Baseline characteristics and procedural data did not differ significantly among the three groups. Total in-hospital mortality was 7.5% (n = 38), 14.4% (n = 20) for group 1, 4.9% (n = 10) for group 2, and 4.9% (n = 8) for group 3, respectively. In-hospital mortality for critical patients was 14% (n = 18), and for noncritical patients it was 3.7% (n = 13). Especially early revascularization of critical patients with reduced LVEF showed a strong association to in-hospital mortality. When excluding critical patients, in-hospital mortality did not vary significantly between groups. Furthermore, early CABG was associated with a higher incidence in platelet (p < 0.001) and erythrocyte (p < 0.015) transfusion, regardless of critical or noncritical status.

Conclusion: Our study demonstrates that in-hospital mortality in noncritical patients presenting with NSTEMI is unattached to timing of revascularization. Revascularization of critical patients is associated with a higher mortality. Especially patients with impaired left ventricular function seem to be at risk when revascularized earlier.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
19 February 2021