Clinical presentation of patients with prior coronary artery bypass grafting and suspected acute myocardial infarction

Abstract

Aims Diagnosis of acute myocardial infarction (AMI) can be challenging in patients with prior coronary artery bypass grafting (CABG). Methods and results Final diagnoses were adjudicated by two independent cardiologists using the universal definition of AMI among patients presenting to the emergency department (ED) with suspected AMI. Diagnostic accuracy of 34 chest pain characteristics (CPCs) and four electrocardiogram (ECG) signatures stratified according to the presence or absence of prior CABG were prospectively quantified. Among 4015 patients (no prior CABG: n = 3686; prior CABG: n = 329), prevalence of AMI and unstable angina were higher in patients with prior CABG (35% vs. 18%; 26% vs. 8%; both P < 0.001). Three CPCs (9%) and two electrocardiographic findings (50%) showed a different diagnostic performance (interaction P < 0.05) with loss of diagnostic value in patients with prior CABG. The diagnostic accuracy as quantified by the area under the curve (AUC) of the integrated clinical judgement was moderate to good in patients with prior CABG, and significantly lower compared to patients without prior CABG [AUC 0.80 (95% confidence interval (CI) 0.75–0.84) vs. AUC 0.87 (95% CI 0.86–0.89); P = 0.004]. Time to discharge from the ED was significantly longer in patients with prior CABG [359 (215–525) min vs. 300 (192–435) min; P < 0.001]. Key findings were confirmed in a large independent external validation cohort (n = 13 653). Conclusions Patients with prior CABG presenting with suspected AMI have a high prevalence of AMI and unstable angina and lower diagnostic accuracy of CPCs and the ECG, possibly justifying liberal use of early coronary angiography in these vulnerable patients. ClinicalTrials.gov registry Number NCT00470587.

Chest Pain in Cancer Patients

“…This was a secondary analysis from the APACE (Advantageous Predictors of Acute Coronary Syndromes Evaluation) study. APACE is a multicenter, international, prospective diagnostic study ( NCT00470587 ), 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 conducted in 12 EDs in 5 different European countries, enrolling patients >18 years of age presenting to EDs with nontraumatic acute chest pain as the main symptom. Patients were excluded if they had had prehospital cardiopulmonary resuscitation, were in shock, or had terminal kidney failure on long-term hemodialysis.…”

Lower diagnostic accuracy of hs-cTnI in patients with prior coronary artery bypass grafting

“…The need for more extensive diagnostic work-up often including cardiac imaging in patients with prior CABG is further emphasized by the high prevalence of MI observed in this vulnerable patient subgroup. [2] Given the difficulty of angiographically identifying the culprit lesion in patients with prior CABG, sophisticated non-invasive imaging using e.g. PET-scanning may by warranted in many patients remaining in the observe-zone.…”

“…In patients with prior coronary artery bypass grafting (CABG) presenting with acute chest pain, the prevalence of acute myocardial infarction (MI) was two-fold higher and that of unstable angina three-fold higher compared to patients without prior CABG. [2] Therefore, it is of major concern that recent pilot studies have suggested that all three pillars of the early diagnosis of MI, chest pain characteristics, 12-lead ECG, and high-sensitivity cardiac troponin T (hs-cTnT) may have lower diagnostic accuracy in patients with prior CABG. [2], [3] While clinical practice and clinical practice guidelines in general assume that the release of cTnI and cTnT into the circulation reflects identical pathophysiological processes,important pathophysiological differences between cTnT and cTnI, including circadian rhythm of cTnT, but not cTnI, and stronger influence of skeletal muscle disease and renal dysfunction on cTnT, as well as possible differences among different hs-cTnI assays, have been reported.…”

“…[2] Therefore, it is of major concern that recent pilot studies have suggested that all three pillars of the early diagnosis of MI, chest pain characteristics, 12-lead ECG, and high-sensitivity cardiac troponin T (hs-cTnT) may have lower diagnostic accuracy in patients with prior CABG. [2], [3] While clinical practice and clinical practice guidelines in general assume that the release of cTnI and cTnT into the circulation reflects identical pathophysiological processes,important pathophysiological differences between cTnT and cTnI, including circadian rhythm of cTnT, but not cTnI, and stronger influence of skeletal muscle disease and renal dysfunction on cTnT, as well as possible differences among different hs-cTnI assays, have been reported. [4][5][6][7][8][9] Since patients with prior CABG surgery represent a vulnerable subgroup with high age, high incidence of diabetes, atherosclerosis, possible remaining chronic myocardial ischemia, and renal insufficiency, it is unknown whether the concern of lower diagnostic accuracy applies also for hs-cTnI, the most widely used analyte.…”

“…[4][5][6][7][8][9] Since patients with prior CABG surgery represent a vulnerable subgroup with high age, high incidence of diabetes, atherosclerosis, possible remaining chronic myocardial ischemia, and renal insufficiency, it is unknown whether the concern of lower diagnostic accuracy applies also for hs-cTnI, the most widely used analyte. [2,3,10,11] Therefore, the aim of this study was to assess the diagnostic accuracy of hs-cTnI and the performance of the corresponding ESC hs-cTnI 0/1h-algorithms in patients with prior CABG using four different hs-cTnI assays [4][5][6][7].…”