The timing of surgical revascularization in acute myocardial infarction: when should we intervene?

INTRODUCTION: Coronary artery bypass grafting (CABG) is a crucial intervention in acute myocardial infarction (AMI), particularly when AMI is not amenable for management with primary percutaneous coronary intervention (PCI). To optimize outcome in these patients, surgical teams must consider a host of predictive factors, with the most prominent being the timing of CABG. Despite numerous studies exploring timing of CABG following AMI in the past, optimal surgical timing remains controversial. The mortality rates vary with timing of CABG, but confounding factors such as age, impaired pulmonary function, renal insufficiency, and poor left ventricular function may contribute to varied outcomes reported. EVIDENCE ACQUISITON: An electronic literature search of articles that discussed acute myocardial presentation and urgent in-patient or elective CABG was conducted. EVIDENCE SYNTHESIS: The evidence was synthesized based on each reported article and their outcomes. CONCLUSIONS: Current literature suggests multiple factors can guide CABG timing including, type of AMI at initial presentation, distinctive pathological status, and patient characteristics. Thus, there is a need for large, multi-center studies to identify optimal CABG timing in complex coronary artery disease or failed PCI in patients with AMI. Future guidelines should emphasize patient cohorts by taking their risk factors into consideration. As such, a need for greater cardiac screening methods and development of scoring systems can aid in the optimization of CABG timing.