title: Patients with non-ST-elevation acute coronary syndromes undergoing coronary artery bypass grafting in the modern era of antithrombotic therapy.
abstract: BACKGROUND
  Many high-risk patients with non-ST-elevation acute coronary syndromes within the SYNERGY trial required coronary artery bypass grafting (CABG) for optimal revascularization. We explored the clinical outcomes among high-risk patients undergoing CABG and the impact of modern pharmacology.
  
  
  METHODS
  We evaluated 180-day rates of death and myocardial infarction (MI) and 30-day GUSTO severe bleeding among patients undergoing CABG, contrasting them with patients undergoing percutaneous coronary intervention (PCI) or medical management. The relationships between perioperative MI, bleeding events, and 6-month mortality were explored. The effect of random assignment to unfractionated heparin or enoxaparin and the relationships between use of clopidogrel and glycoprotein IIb/IIIa inhibitors and clinical outcomes were assessed.
  
  
  RESULTS
  Death or MI at 6 months was more common among patients requiring CABG (CABG 31.2%, PCI 15.9%, medical 9.9%). Thirty-day GUSTO severe bleeding was also higher (CABG 6.4%, PCI 1.1%, medical 0.9%). Perioperative MI and GUSTO severe bleeding were associated with excess 6-month mortality (hazard ratio 2.1, 95% CI 1.27-3.53 and hazard ratio 7.6, CI 4.78-12.09, respectively). Randomization to enoxaparin was not associated with an increase in bleeding or a reduction in death or MI. No differences in ischemic outcomes were observed among patients given glycoprotein IIb/IIIa inhibition or clopidogrel.
  
  
  CONCLUSIONS
  High-risk patients still commonly require CABG with greater bleeding and ischemic event rates observed. Current definitions of perioperative MI and GUSTO severe bleeding portend an increased in 6-month mortality among CABG patients. Modern pharmacotherapies do not appear to impact these higher event rates.
authors.affiliation: Flinders Medical Centre, South Australia, Adelaide, Australia. derek.chew@flinders.edu.au
authors.forename: Derek P
authors.initials: DP
authors.lastname: Chew
authors.forename: Zhen
authors.initials: Z
authors.lastname: Huang
authors.forename: Karen S
authors.initials: KS
authors.lastname: Pieper
authors.forename: Harvey
authors.initials: H
authors.lastname: White
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.forename: James J
authors.initials: JJ
authors.lastname: Ferguson
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.forename: Philip G
authors.initials: PG
authors.lastname: Aylward
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery*; D000368:Aged; D000077144:Clopidogrel; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality*; D004562:Electrocardiography; D017984:Enoxaparin / Q000627:therapeutic use; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D019106:Postoperative Hemorrhage / Q000209:etiology; D016019:Survival Analysis; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D017984:Enoxaparin; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine