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Objective: The study objective was to assess the impact of chronic total occlusion on long-term graft failure and outcomes in patients who underwent coronary artery bypass grafting., Methods: We conducted an observational study involving a single-center subgroup of the CORONARY trial. At 6 to 9 years after coronary artery bypass grafting, all alive patients were invited for coronary computed tomography angiography and clinical follow-up. We assessed the association between chronic total occlusion graft and failing graft showing Fitzgibbon type B or O. Risk factors associated with chronic total occlusion graft failure were assessed. The impact of chronic total occlusion on clinical outcomes was analyzed, including death, myocardial infarction, and repeated revascularization., Results: A total of 349 patients undergoing coronary artery bypass grafting were enrolled between May 2007 and October 2011. Of 301 alive patients at follow-up time (median, 6.8 years; interquartile range, 6.0-8.0 years), repeat coronary computed tomography angiography was performed in 206 patients (68.4%) with 723 grafts (154 chronic total occlusion grafts and 569 nonchronic total occlusion grafts). Chronic total occlusion graft was significantly associated with an increased risk of long-term graft failure after adjustment for patient- and graft-level characteristics (adjusted odds ratio, 2.27; 95% confidence interval, 1.42-3.62; P < .001). Arterial graft, side-to-side anastomosis, higher graft flow, and antiplatelet therapy at discharge were associated with chronic total occlusion graft patency. The presence of 1 or more chronic total occlusions was not significantly associated with long-term composite of death, myocardial infarction, or repeat revascularization (adjusted hazard ratio, 0.91; 95% confidence interval, 0.54-1.51; P = .707)., Conclusions: Chronic total occlusion graft was associated with an increased risk of graft failure. Surgical technique and guideline-directed medical therapy should be noted to improve chronic total occlusion graft patency., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The optimal preoperative antiplatelet strategy for patients with acute coronary syndrome (ACS) requiring surgical revascularization remains unclear because of competing risks of bleeding and ischemic events. We evaluated the effect of clopidogrel within 5 days before coronary artery bypass grafting (CABG) on outcomes in patients with ACS., Methods: Consecutive patients with ACS who underwent isolated CABG at a single center were included in this retrospective study. The primary outcome was a composite of death, myocardial infarction, and stroke within 30 days after surgery. Secondary outcomes were CABG-related major bleeding and perioperative transfusion. Inverse probability weighting using propensity score was performed to evaluate the risk-adjusted effect of preoperative clopidogrel on outcomes., Results: Of 5543 patients with ACS, 820 (14.8%) patients continued clopidogrel within 5 days before CABG. After adjustment for differences in baseline factors, clopidogrel use ≤5 days before CABG was associated with significantly increased odds of the primary composite outcome (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.16-2.29; P = .005), stroke (OR, 3.13; 95% CI, 1.82-5.39; P < .001), major bleeding (OR, 2.01; 95% CI, 1.56-2.58; P < .001), and transfusion (OR, 2.05; 95% CI, 1.82-2.30; P < .001). The effects of preoperative clopidogrel use ≤5 days on primary outcome and major bleeding were greater in patients older than 65 years., Conclusions: Among patients with ACS undergoing CABG, clopidogrel therapy within 5 days before surgery was associated with increased odds of major cardiac and cerebrovascular events and bleeding complications than discontinuing clopidogrel for >5 days., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Studies found that patients who underwent coronary artery bypass grafting (CABG) often fail to receive optimal evidence-based secondary prevention medications. We evaluated the effectiveness of a smartphone-based quality improvement effort on improving the prescription of medical therapies., Methods: In this cluster-randomized controlled trial, 60 hospitals were randomized to a control arm (n = 30) or to an intervention arm using smartphone-based multifaceted quality improvement interventions (n = 30). The primary outcome was the prescription of statin. The secondary outcomes were prescription of beta-blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker (ACE inhibitor or ARB), and optimal medical therapy for eligible patients., Results: Between June 1, 2015 and September 15, 2016, a total of 10,006 CABG patients were enrolled (5,653 in 26 intervention and 4,353 in 29 control hospitals, 5 hospitals withdrew). Statin prescribing rate was 87.8% in the intervention arm and 84.4% in the control arm. We saw no evidence of an effect of intervention on statin prescribing in the intention-to-treat analysis (odds ratio [OR], 1.31; 95% confidence interval (CI), 0.68-2.54; P = .43) or in key patient subsets. The prescription rates of ACE inhibitor or ARB and optimal medical therapy were comparable between study groups, while beta-blocker was more often prescribed in the intervention arm. Post hoc analysis demonstrated a greater increase in statin prescribing rate over time in the intervention arm., Conclusions: A smartphone-based quality improvement intervention compared with usual care did not increase statin prescribing for patients who received CABG. New studies focusing on the best practice of this technique may be warranted., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Secondary preventive therapies play a key role in the prevention of adverse events after coronary artery bypass grafting (CABG). However, adherence to secondary preventive drugs after CABG is often poor. With the increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve medication adherence. We aimed to evaluate the effectiveness and feasibility of using a smartphone-based application to improve medication adherence in patients after CABG., Methods: The Measurement and Improvement Studies of Surgical coronary revascularizatION: medication adherence (MISSION-2) study is a multicenter randomized controlled trial that planned to enroll over 1000 patients who underwent isolated CABG at one of four large teaching hospitals in China; all enrolled participants had access to a smartphone and were able to operate at least three smartphone applications. The investigators randomly assigned the participants to one of two groups: (1) the intervention group with an advanced smartphone application for 6 months which was designed specifically for this trial and did not exist before. Participants could receive medication reminders and cardiac health education by the smartphone application or (2) the control group with usual care. The primary outcome was CABG secondary preventive medication adherence as measured by the translated Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) at 6 months after randomization. The secondary outcomes were mortality, major adverse cardiovascular and cerebrovascular events (MACCE), cardiovascular rehospitalization, self-reported secondary preventive medication use after 6 months of follow-up, blood pressure (BP), body mass index (BMI), and self-reported smoking status. All analyses were conducted using the intention-to-treat principle., Results: A total of 1000 patients (mean age, 57.28 [SD, 9.09] years; 85.5% male) with coronary heart disease after CABG were enrolled between September 2015 and September 2016 and were randomly assigned to the intervention (n = 501) or control group (n = 499). At 6 months, the proportion of low-adherence participants, categorized by MMAS-8 scores, was 11.8% in the intervention group and 11.7% in the control group (RR = 1.005, 95% CI 0.682 to 1.480, P = 1.000). Similar results were found in sensitivity analyses that considered participants who withdrew from the study, or were lost to follow-up as nonadherent. There were no significant differences in the secondary clinical outcome measures, and there were no significant differences in the primary outcome across the subgroups tested. In the intervention group, the proportion of participants who used and operated the application during the first month after CABG was 88.1%; however, the use rate decreased sharply from 42.5% in the second month to 9.2% by the end of the study (6 months)., Conclusions: A smartphone-based application supporting secondary prevention among patients after CABG did not lead to a greater adherence to secondary preventive medications. The limited room for improvement in medication adherence and the low participants' engagement with the smartphone applications might account for these non-significant outcomes., Competing Interests: Disclosures None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: The benefits of secondary preventive drugs after coronary artery bypass grafting have been thoroughly established. However, the prescription rates of these drugs are low at discharge in China. We sought to evaluate the effectiveness of continuous quality improvement with mobile-based interventions for clinicians on improving the guideline-adherence of secondary preventive drugs prescription., Methods and Results: The quality MISSION-1 study is a cluster-randomized controlled trial. We enrolled 60 hospitals with a bypass surgery volume of more than 30 a year and randomly assigned them into the intervention group or the control group in a 1:1 ratio using minimized random grouping. The intervention group undertakes a series of mobile-based interventions, while the control group maintains a routine practice pattern. All sites consecutively register patients who underwent isolated coronary artery bypass grafting and submit in-hospital data. We require supporting documents regarding prescription information at discharge to adjudicate the outcome measures. The estimated sample size of enrolled patients is 9,600. The primary outcome measure is the prescription rate of statins for eligible patients at discharge. The secondary outcome measures are β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and optimal medical therapy. MISSION-1 study is now recruiting patients., Conclusions: The MISSION-1 study has the potential to identify the effectiveness of interventions on improving secondary prevention adherence at discharge after bypass surgery in China and further disseminate findings to other settings to improve the quality of care., (Copyright © 2016. Published by Elsevier Inc.)