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Optimal Timing of Coronary Artery Bypass After Acute Myocardial Infarction: A Review of California Discharge Data
E. S. Weiss, D. D. Chang, D. Joyce, L. U. Nwakanma, D. D. Yuh. Johns Hopkins Hospital, Baltimore, MD,
BACKGROUND:
The optimal timing for CABG after acute myocardial infarction (AMI) is not well established. The California Discharge Database allows examination of this issue free of institutional bias. We examine the effect of timing of CABG after AMI upon short-term outcomes.
METHODS:
We reviewed the California Discharge Database between 1999-2003 to identify 6,924 patients who were hospitalized for AMI (day 0) and underwent subsequent CABG. Patients were stratified by timing of CABG to early (day 0-2) and late groups (day 3 or later). The primary outcome variable was all-cause hospital mortality. Secondary outcome variables included new dialysis, prolonged ventilation (> 96 hours), wound infection, and postoperative hospital length of stay (LOS). Multiple logistic and linear regression assessed risk of adverse events, controlling for factors associated with high preoperative clinical acuity including the Charlson comorbidity index, shock, mechanical ventilation, and IABP use.
RESULTS:
Of 6,924 patients identified, 3,372 (49%) were in the early CABG group and 3,541 (51%) were in the late group. 330 patients (5%) died during hospitalization with a peak mortality rate of 8.3% among patients undergoing CABG on day 0, declining to a nadir of 2.7% among patients undergoing CABG on day 3 (Figure). Mean time to CABG was 3.3 days. Early CABG patients had higher mortality than late CABG patients (5.8% vs. 3.8%, p < 0.001). Early CABG was an independent predictor of mortality after controlling for clinical acuity (odds-ratio 1.5, P < 0.01). Patients undergoing CABG on day 0 had a higher rate of dialysis (3.3% vs. 2.2%, p = 0.03) and longer postoperative LOS (8.5 vs. 7.5 days, p = 0.006). Wound infection and prolonged ventilation rates were not significantly different among groups.
CONCLUSIONS:
We report the largest series studying the effect of CABG timing after AMI on short-term outcomes. Patients undergoing CABG within two days of hospitalization for AMI had higher mortality rates than those undergoing CABG three or more days after AMI, independent of clinical acuity. This suggests CABG may best be deferred for three or more days after admission for AMI in non-emergent cases. 
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