Long-term survival and cardiac troponin T elevation in on- and off-pump coronary artery bypass surgery.

INTRODUCTION: The long-term clinical usefulness of conventional coronary artery bypass graft surgery (CCAB) versus off-pump surgery (OPCAB) remains controversial. Long-term survival and elevation in cardiac troponin T (cTnT) concentration following CCAB and OPCAB have not been assessed. We tested the hypothesis that long-term survival rates for CCAB and OPCAB patients were similar when stratified by cTnT concentration. METHODS AND RESULTS: In this prospective cohort, we followed 1511 nonemergency patients with 2- or 3-vessel disease (778 CCAB and 733 OPCAB cases) from a hospital in northern New England to determine if 6-year survival rates for CCAB and OPCAB patients were similar. The patients underwent surgery between 2000 and 2004 by surgeons who used both procedures. Postoperative cTnT elevation was defined as > or =1 ng/mL, the upper quartile of cTnT values. Data were linked to the Social Security Administration Death Master File. Kaplan-Meier analysis and Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI), with adjustments for baseline patient and disease characteristics. Patients were followed for a median of 4.1 years (mean, 4.0 years). Patients were similar with regard to baseline disease characteristics, comorbidities, cardiac history, function, and anatomy. OPCAB was associated with increased rates of postoperative bleeding and with a worse 6-year survival rate compared with CCAB, regardless of cTnT concentration (cTnT <1 ng/mL, P < .013; cTnT > or =1 ng/mL, P = .017). Compared with CCAB patients, the adjusted HR (95% CI) was 1.59 (1.09-2.32) for OPCAB patients with cTnT concentrations <1 ng/mL and 1.93 (1.12-3.31) for OPCAB patients with cTnT concentrations > or =1 ng/mL. CONCLUSION: Survival is better for CCAB patients than for OPCAB patients, regardless of cTnT concentration. This effect is sustained after multivariable adjustment for baseline mortality risk factors.

Cardiac troponin T levels in on- and off-pump coronary artery bypass surgery.

BACKGROUND: Conventional coronary artery bypass graft surgery (CCAB) has been associated with greater myocardial injury than off-pump surgery (OPCAB). However, the extent of myocardial injury following CCAB and OPCAB has not been assessed by priority of surgery or the number of diseased vessels. We tested the hypothesis that the additional myocardial injury associated with CCAB compared with OPCAB is sustained when patients are stratified by priority and 2- or 3-vessel disease. METHODS AND RESULTS: In this prospective cohort, we measured 24-hour postoperative cardiac troponin T (cTnT) following CCAB and OPCAB surgery to determine if OPCAB results in less perioperative myocardial damage by priority (urgent or elective). We studied 1511 patients who underwent heart surgery in one hospital in northern New England between 2000 and 2004. Surgeons used either CCAB (778 patients) of OPCAB (733 patients). Unpaired t tests were used to test the mean difference in cTnT between CCAB and OPCAB subgroups. Mean cTnT levels were significantly higher in the CCAB group (0.94 ng/mL) than the OPCAB group (0.18 ng/mL) with P < .001; this difference was consistent across urgent and elective surgeries, and patients with both 2- and 3-vessel disease. CCAB patients consistently demonstrated higher cTnT levels. Similar results were evident when stratified by patient characteristics and surgeon. CONCLUSIONS: In summary, higher postoperative cTnT levels are associated with CCAB than with OPCAB, regardless of priority, number of diseased vessels, patient characteristics, or surgeon. OPCAB results in less myocardial injury in patients, whether they present with 2- or 3-vessel disease and whether they undergo urgent or elective cardiac surgery.

Prenatal alcohol intake in a rural, caucasian clinic.

BACKGROUND AND OBJECTIVES: This study examined prior use and psychosocial factors associated with alcohol and/or drug use in pregnant women from a predominantly Caucasian, rural clinic in northeastern Maine. METHODS: We conducted archival record reviews of 217 pregnant women who delivered at the Family Practice Clinic of Eastern Maine Medical Center As part of the standard initial prenatal visit during thefirst trimester, a nurse practitioner interviewed and collected data from pregnant women concerning pre-pregnancy and current-pregnancy use of alcohol, tobacco, and other drugs. Data were available for 212 subjects. RESULTS: The reported prevalence of pre-pregnancy alcohol abuse in this sample was 25%. Women in this cohort reported a significant decrease in tobacco and alcohol use following pregnancy awareness. However, pre-pregnancy alcohol intake levels and years of alcohol use were associated with alcohol intake during pregnancy. Other markers of maternal alcohol intake during pregnancy included tobacco use patterns and history of drug use. Family history of alcohol problems and drug use were associated with maternal substance use history and use by the father of the baby. Levels of maternal alcohol use during the current pregnancy were negatively associated with an alcohol problem in the father of the baby. CONCLUSIONS: Alcohol and other substance use were relatively common in our sample of rural Caucasian women in Maine. Several risk factors can be identified, and awareness of these risk factors may assist physicians in the diagnosis of substance abuse among pregnant women.