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Ann Thorac Surg 2009;88:789-795. doi:10.1016/j.athoracsur.2009.04.097
© 2009 The Society of Thoracic Surgeons
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Right arrow Coronary disease

Original Articles: Adult Cardiac

Statin Treatment Equalizes Long-Term Survival Between Patients With Single and Bilateral Internal Thoracic Artery Grafts

Michel Carrier, MDa,*, Mariève Cossette, MSb, Michel Pellerin, MDa, Yves Hébert, MDa, Denis Bouchard, MDa, Raymond Cartier, MDa, Philippe Demers, MDa, Hugues Jeanmart, MDa, Pierre Pagé, MDa, Louis P. Perrault, MDa

a Department of Cardiac Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
b Montreal Heart Institute Coordinating Center (Biostatistic), Montreal, Quebec, Canada

Accepted for publication April 24, 2009.

* Address correspondence to Dr Carrier, Department of Cardiac Surgery, Montreal Heart Institute and Université de Montréal, 5000 Belanger St, Montreal, Quebec, H1T 1C8, Canada (Email: michel.carrier{at}icm-mhi.org).

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 
Background: The use of 2 internal thoracic artery (ITA) grafts increases survival 10 years after coronary artery bypass grafting (CABG) compared with single ITA grafting. Statin treatment was also shown to decrease development and progression of saphenous vein graft atherosclerosis. This study examined the effect of statin treatment on long-term survival after CABG.

Methods: Operative, survival, and pharmacologic data of 6655 patients who underwent CABG with ITAs between 1995 and 2007 in our institution were obtained.

Results: Patients with bilateral ITA grafts had an average 10-year-survival rate of 83% ± 2% compared with 67% ±1% in patients with single ITA grafts (p = 0.0001). Statin treatment caused a significant decrease in the long-term risk of death among patients who underwent single ITA grafting (hazard ratio [HR], 0.735, p = 0.0001). However, statin treatment had no effect on the risk of long-term death among patients who underwent bilateral ITA grafting (HR, 1.053; p = 0.7806).

Conclusions: Statin treatment initiated early after grafting improved long-term survival in patients with a single ITA graft but not in those with bilateral ITA grafts. Survival of statin-treated patients with single ITA grafts was similar to bilateral ITA patients.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 References
 
At first, single then bilateral internal thoracic artery (ITA) grafting was shown to improve patient survival at 10 years compared with the use of saphenous vein grafts [1–9]. The bilateral ITA grafts for arterial grafting became the procedure of choice for patients undergoing multiple coronary artery bypasses grafting (CABG) [10, 11]. Because most studies supporting these recommendations were obtained from patients operated on in the 1980s and 1990s, before the use of statin treatment to control lipid levels after CABG, most patients did not receive treatment with proven measures of secondary prevention after significant coronary clinical events.

The Post Coronary Artery Bypass Graft (Post CABG) trial studying 1351 patients at 1 to 11 years after CABG demonstrated a clear benefit of an aggressive lowering of low-density lipoprotein cholesterol (LDL-C) to below 100 mg/dL with lovastatin on the angiographic progression of atherosclerosis in saphenous vein grafts [12]. Treatment with aspirin, β-blockers, and especially a statin, must have a significant effect on long-term survival and complication rates that needs to be studied in addition to the simple definition of the surgical technique in single and bilateral ITA grafts.

The objective of the present study is to analyze the benefit of secondary prevention with medication, including statin treatment, and single and bilateral ITA grafts on long-term survival after CABG. We hypothesized that statin treatment initiated early after CABG provides a significant long-term protection against death and coronary events. We also tested the hypothesis that the protection effect of statin treatment on long-term coronary events causes a substantial modification of the effect of using a single ITA graft.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 References
 
Between January 1995 and December 2007, 9980 consecutive adult patients underwent primary and isolated CABG with ITA grafting at the Montreal Heart Institute. All patients undergoing CABG with at least one ITA graft were included in the present analysis. Patients undergoing a concomitant valve or other cardiac surgical procedures were excluded, as well as patients undergoing reoperation.

The indication for myocardial revascularization was based on standard angiographic and clinical criteria. The left ITA was harvested with its pedicle and usually grafted on the left descending artery or a diagonal branch; when used, the right ITA was mostly harvested pedicle aiming at the circumflex or the right coronary territory or used as a free graft [7]. Sequential ITA grafts were used occasionally. Patients underwent single and bilateral ITA grafting depending on the preference of the attending surgeon.

Demographic variables (gender and age) and risk factors for coronary artery disease and major comorbidities were obtained by retrospective review of the institutional discharge summary.

Patient survival during follow-up and the occurrence of cardiac reoperation and percutaneous coronary interventions (PCI) were recorded. Follow-up data were obtained by matching the patients' health insurance number in the institutional database with the corresponding files in a governmental centralized health care database (Régie de l'Assurance Maladie du Québec), where all episodes of health care (in and out of the hospital) are recorded. Deaths were obtained from the national index of the provincial government.

The drug insurance program covered all unemployed and also elderly persons in the province before 1997. After this date, all citizens had to register with a private or with the government drug insurance program. All drugs prescribed under the public system were recorded and the data were available for our analysis.

Patients were separated in three subgroups according to the use of specific classes of medication after CABG: (1) no use of the medication, (2) the prescription starting after the first 30 postoperative days, and (3) prescription of the medication starting within 30 days of the operation and continuing until the last year of follow-up. The decision to use the 30-day cutoff was arbitrary considering the hypothesis that medical treatment initiated early after the operation might give better long-term results after CABG.

Four classes of medication were studied: antiplatelet agents, β-blockers, statins, and angiotensin-converting enzyme (ACE) inhibitors. A prescription of one agent in each class was considered as present or absent, irrespective of the doses and the trade names of the particular drug.

Permission to use the denominated database was obtained from the Information Access Board of the Quebec government and from the Ethics Committee of the Montreal Heart Institute. Follow-up was complete except for 81 patients, who were mostly foreign, where the health insurance number was unavailable (9880 [99%] of 9918 of complete data). All information, clinical follow-up, and vital status was obtained until October 2007, the closing interval for our cohort of patients.

Statistical Analysis
Data were expressed as means ± standard deviation for continuous variables and frequencies and percentages for categoric variables. Demographic data were compared between groups using {chi}2 test for categoric variables, and continuous variables were compared using the t test. Mortality at 30 days was analyzed for the entire cohort of 9875 patients. Long-term survival was studied with hospital survivors followed up under the public insurance program, thus including 6655 patients. Mortality, PCI, cardiac reoperation, and the combination of all adverse events were studied using survival analysis.

Survival curves were computed using the Kaplan-Meier formulas and compared between groups with the log-rank test. Cox proportional hazard multivariate regression model was used to analyze the effect of ITA graft techniques and the use of a statin on long-term mortality rates and the combination of all adverse events adjusted for demographic, clinical, and medication covariates. All analyses were done with SAS 9.1 software (SAS Institute Inc, Cary, NC) and conducted at a significance level of 0.05.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 References
 
Patient Characteristics
Patients registered in the public drug program were significantly older, a larger percentage were women, and they had a higher rate of diabetes and hypertension compared with patients insured in the private program (Table 1). Antiplatelet agents and statins were the medications most often used after CABG in patients with public insurance coverage (Table 2).


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  		Table 1 Patient Characteristics
 

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  		Table 2 Medications After Coronary Artery Bypass Grafting in Patients Participating in the Drug Public Insurance Program
 
Patients with public insurance coverage who underwent CABG with bilateral ITA grafts were younger, most likely men with hyperlipidemia, and were less likely to have diabetes compared with patients who underwent CABG with a single ITA graft. Use of the four classes of medication after CABG was similar in bilateral and single ITA graft patients, although a greater proportion of bilateral ITA patients were receiving statin treatment within 30 days of CABG (Table 3).


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  		Table 3 Clinical Characteristics and Medications According to the use of Single and Bilateral ITA Grafts in Patients Participating to the Public Drug Insurance Program
 
Short-Term Results
The 30-day mortality was 175 of 7269 (2.4%) in single ITA patients and 17 of 2602 (0.7%) in bilateral ITA patients (p = 0.0001).

Survival, PCI, and Redo CABG at Follow-Up
Patients who underwent CABG with bilateral ITA grafts had a 10-year-survival rate averaging 83% ± 2% compared with 67% ± 1% in patients with single ITA grafts (p = 0.0001). The freedom rate from coronary angioplasty during follow-up averaged 89% ± 1% in patients with bilateral ITA grafts and 88% ± 1% in those with single ITA grafts (p = 0.6859). Freedom rate from CABG reoperation averaged 99% ± 1% in patients with bilateral ITA grafts and 99% ± 1% in those with single ITA grafts (p = 0.9165). The freedom rate from major cardiac events, including death, coronary angioplasty, and reoperation during follow-up averaged 73% ± 2% in patients with bilateral ITA grafts and 59% ± 1% in patients with a single ITA graft (p = 0.0001).

Multivariate Analyses
Patients covered with the public insurance drug program
Cox proportional hazard multivariate regression model for time to death after CABG was performed in regrouping patients in two categories of classes of medication. First, patients without a drug prescription and those with prescriptions starting after 30 days of CABG; and second, those patients with prescription starting within 30 days after CABG and continuing until the last year of follow-up. Preoperative risk factors of Table 1, CABG with single and bilateral ITA grafts, and the medication category were included in the model.

Age and diabetes increased the risk of death after CABG (Table 4). Female gender and a preoperative diagnosis of hyperlipemia were associated with an improvement in survival after CABG. Use of antiplatelet agents, β-blockers, and statins was associated with an improvement in survival rates, whereas ACE inhibitor was associated with a greater risk of death after CABG. Overall, bilateral ITA grafting was associated with a significant improvement in survival after CABG.


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  		Table 4 Cox Regression Multivariate Analysis for Time to Death Analysis Including all Patients Insured with the Public Drug Program
 
The interaction between ITA graft and statin use was investigated and showed a slight but not significant trend (hazard ratio [HR], 1.432; p = 0.064). Statin treatment caused a significant decrease in the long-term risk of death among patients who underwent single ITA grafting (HR, 0.735; p = 0.0001). However, statin treatment had no effect on the long-term risk of death among patients who underwent bilateral ITA grafting (HR, 1.053; p = 0.7806; Fig 1).


Figure 1
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  		Fig 1. Adjusted actuarial survival for the entire cohort of 6655 patients. These curves were adjusted for all risk factors described in Table 4. Among patients treated with statin medication, patients who underwent single and bilateral internal thoracic artery (ITA) grafting had a similar survival.

 
The rate of major cardiac events, including death, coronary angioplasty, and reoperation 10 years after CABG averaged 41% in single ITA and 27% in bilateral ITA graft patients. The Cox proportional hazard multivariate regression model showed that bilateral ITA grafts decrease the risk to 0.767 (p = 0.0047); and for single ITA patients, the use of statin treatment within 30 days after CABG decreased the risk to 0.799 (p = 0.0002) of the latter risk.

Patients with 3-vessel coronary artery disease
Statin treatment and the use of bilateral ITA grafts were associated with better chance of survival after CABG. The interaction between the ITA graft and use of a statin was statistically significant (HR, 1.604; p = 0.0295). Statin treatment caused a significant decrease in the risk of death among patients who underwent single ITA grafting (HR, 0.728; p = 0.0002) but had no effect on patients who underwent bilateral ITA procedures (HR, 1.168; p = 0.4506; Table 5, Fig 2).


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  		Table 5 Cox Regression Multivariate Analysis for Time to Death Analysis Including Only Patients with 3-Vessel Coronary Artery Disease
 

Figure 2
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  		Fig 2. Adjusted actuarial survival for 4963 patients with 3-vessel disease. Among patients treated with statin medication, patients who underwent single and bilateral internal thoracic artery (ITA) grafting had a similar survival.

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 References
 
The present study suggests that secondary prevention measures with statin treatment have a significant effect on long-term survival after CABG, not only increasing survival overall but also causing a substantial modification of the effect of ITA grafting techniques on survival. Survival of patients who underwent single ITA grafting was significantly improved with early initiation of statin treatment after CABG, although the use of a statin had no survival advantage to those patients who underwent bilateral ITA grafting.

Several studies have shown a long-term survival benefit of both bilateral ITA grafting and statin treatment after CABG. The use of single and bilateral ITA grafts is the method of choice for patients undergoing CABG [2–6]. Primary and secondary prevention after significant coronary events was recognized not only to improve survival but also to decrease progression of obstructive changes in saphenous vein CABG [12].

Goyal and colleagues [13] showed that the use of antiplatelet agents and β-blockers at discharge was associated with a lower hazard of death 2 years after CABG. The 2-year follow-up of the Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV study was not of sufficient duration after CABG to detect a clinical benefit from lipid-lowering therapy. The Post-CABG trial showed that an aggressive strategy to lower LDL-C resulted in a clear clinical benefit 7.5 years after enrollment and supports the recommendation that LDL-C levels should be reduced to less than 100 mg/dL in patients who have coronary artery disease [14].

Mangano [15] also demonstrated a significant benefit with the use of aspirin early after CABG in a large multicenter study. Ferguson and colleagues [16] showed benefit of the preoperative use of β-blockers in improving early outcomes after CABG. The present study supports previous results suggesting improvement in survival 10 years after CABG with β-blockers.

On the other hand, Rouleau and colleagues [17] not only demonstrated no benefit with the use of an ACE inhibitor after CABG but an increase in the incidence of adverse events in the Ischemia Management with Accupril Post Bypass Graft via Inhibition of Angiotensin Converting Enzyme (IMAGINE) clinical trial. Our data suggest that the use of an ACE inhibitor is associated with a higher risk of death during the 10-year follow-up in our cohort. This finding could simply be related to patient selection for the medication, because our analysis is based on a retrospective cohort.

Statin treatment not only affects cholesterol levels but also reduces inflammatory reaction after CABG through various mechanisms. Chello and colleagues [18, 19] suggested an increase in neutrophil apoptosis and an attenuation of leucocyte-endothelial interactions with simvastatin administered preoperatively. Lazar and colleagues [20] showed that pretreatment with statins enhances myocardial protection in an animal model. Moreover, in their analysis of the Post-CABG trial, Domanski and colleagues [21] suggested the presence of a dose-dependent therapeutic effect of lovastatin treatment on saphenous vein graft atherosclerosis progression that is independent of LDL-C lowering.

Kulik and colleagues [22] studied 7503 Medicare patients aged 65 years and older who underwent CABG between 1995 and 2003. Results demonstrated that statin use within 1 month of CABG discharge independently reduced the risk of all-cause mortality compared with no statin use. Data from the present cohort support results published in the latter studies. Our study suggests that the effect of statin treatment is not exclusively related to a decrease in LDL-C levels but also to a pleiotropic effect on several aspects of the postoperative inflammatory reaction in addition to protection of native coronary arteries as well as the integrity of the saphenous vein graft.

The present study suggests that early initiation of statin treatment improves patient survival in protecting saphenous vein grafts and possibly improving long-term patency among patients who underwent single ITA grafting associated with vein grafts. Among patients with bilateral ITA graft, it is of interest that statin treatment did not further enhance long-term survival postoperatively.

These results should be interpreted with caution due to the following limitations. First, we were unable to obtain data on patients within the private drug insurance group. Of interest, these patients were younger and appear to be at much lower risk compared with the patients with public insurance.

Second, we have no data on baseline and actual LDL-C levels before and after CABG. We did not consider changes in dosage and in the subcategories of statins prescribed by physicians because of the many changes observed in dosing and in the company products used throughout the period of the study.

Third, we stress that our conclusion applies only to patients with similar characteristics in terms of age group and of other covariates with an average follow-up of 6 years to a maximum follow-up of 12 years.

In conclusion, measures of secondary prevention, including the use of aspirin, β-blocker, and statin medications, have a significant benefit on long-term survival after CABG. Statin treatment initiated early after the procedure improved long-term survival in patients with single ITA but not in those with bilateral ITA techniques. Survival of statin-treated patients with single ITA grafts was similar to statin-treated and untreated patients with bilateral ITA grafts. The use of statin within 30 days postoperatively equalizes survival between patients with single and bilateral ITA techniques.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
References
 
DR FRIEDRICH MOHR (Leipzig, Germany): Very interesting data. Of course, the message could be that the statins prevent sclerosis of the vein grafts and that could be the reason why you do not see a MACE [major adverse cardiovascular event] in comparison to the bilateral ITA grafts. Do you have any data about symptomatic graft stenosis or graft occlusion?

DR CARRIER: The only solid data we have on this is the Post CABG [coronary artery bypass grafting] trial published a few years ago, which significantly showed that there is a decrease and a blockade in the progression of atherosclerosis in saphenous vein grafts in patients treated aggressively. And in those years, we didn't have, again, the powerful medication we do have now. With the last generation of statin that is available, it can be even more aggressive than it was in those years.

I think that there is a lot of data which supports the fact that progression, of atherosclerosis in the saphenous vein graft will be significantly reduced in aggressively treated patients.

DR A. PIETER KAPPETEIN (Rotterdam, Netherlands): Thank you for the interesting presentation. You highlight in your results the positive effects of statins and β-blockers. What you also showed is that the use of ACE [angiotensin-converting enzyme] inhibitors has an odds ratio of 1.3, which means a higher incidence of MACE or death. Can you explain that?

DR CARRIER: ACE inhibitors, in a few recent randomized trials, have not shown any protection effect. In fact, there have been trials that have suggested that it increased the risk of complications after surgery, at least at long-term. It might be just an effect of a patient selection effectively. We probably did select a subpopulation of patients at lower ejection fraction as well as diabetes patients. But again, there have been some trials recently suggesting that ACE inhibitor is not beneficial to this group of patients at long-term.

DR KAPPETEIN: Right. But it might be that there is a confounding factor like ejection fraction.

DR CARRIER: It could be. I agree with you. And obviously in this kind of database, it is not identified properly.

DR MOHR: Can your data have a misleading message? Because there are so many surgeons who just don't do bilateral IMA [internal mammary artery] grafting around the world. And just listening to you right now, one might sit down and relax and say, you know, I just give some statins and don't worry about the second IMA. Do you have an answer for these?

DR CARRIER: We still use bilateral ITA graft for young patients, it is obvious. But our patient population profile has changed a lot in the last few years, and we see more and more elderly and mid-70s, late-70s, and obviously in these patients, we are reluctant to use the bilateral ITA. But I can tell you that in young patients, we still look at it and if there are no contraindications we use the bilateral ITA.

I tried to stress in the limitation of this study that the average follow-up is 6 years and the maximum follow-up is 12 years. It is not that bad. But it may be a little too short to show differences with the bilateral ITA grafts. I am not trying to say that we shouldn't use bilateral, but I am certainly trying to say that all our patients should be treated with statins right after surgery. Not only that, I think that in the future reports of long-term results after CABG, investigators will have, and the authors will have, to give us not only the pre-op characteristic but also the postoperative treatment of these patients, because I think that it has a significant impact on survival at 6 to 10 years.

DR HORMOZ AZAR (Norfolk, VA): Congratulations on a nice study. Do you think we see the effect of statins or in fact statins act as a marker for patients who take care of themselves in a variety of ways such as diet, exercise, etc. In other words aren't we seeing the cumulative effects of changes in life style and compliance to medical management in these patients?

DR CARRIER: Well, I would be hoping that you are right, but I don't think so. I mean, Canadian patients are probably, as it is in the U.S. They tend to take the pills but not really lose weight and keep going with physical exercise. But I would say that, as you all know, a measure of secondary prevention using change in personal habits has always been difficult. But our hypothesis is that it is mainly related to the drugs, not in the change of the lifestyle.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 

  1. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal mammary artery on 10-year survival and other cardiac events N Engl J Med 1986;314:1-6.[Medline]
  2. Lytle BW, Blackstone EH, Loop FD, et al. Two internal thoracic artery grafts are better than one J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
  3. Buxton BF, Komeda M, Fuller JA, Gordon I. Bilateral internal thoracic artery grafting may improve outcome of coronary artery surgery. Risk-adjusted survival. Circulation 1998;98(19 suppl):II1-II6.[Medline]
  4. Carrel T, Horber P, Turina MI. Operation for two-vessel coronary artery disease: midterm results of bilateral ITA grafting versus unilateral ITA and saphenous vein grafting Ann Thorac Surg 1996;62:1289-1294.[Abstract/Free Full Text]
  5. Cosgrove DM, Lytle BW, Loop FD, et al. Does bilateral internal mammary artery grafting increase surgical risk? J Thorac Cardiovasc Surg 1988;95:850-856.[Abstract]
  6. Dewar LR, Jamieson WR, Janusz MT, et al. Unilateral versus bilateral internal mammary revascularization. Survival and event-free performance. Circulation 1995;92(9 suppl):II8-II13.[Medline]
  7. Farinas JM, Carrier M, Hebert Y, et al. Comparison of long-term clinical results of double versus single internal mammary artery bypass grafting Ann Thorac Surg 1999;67:466-470.[Abstract/Free Full Text]
  8. Fiore AC, Naunheim KS, Dean P, et al. Results of internal thoracic artery grafting over 15 years: single versus double grafts Ann Thorac Surg 1990;49:202-208.[Abstract/Free Full Text]
  9. Gansera B, Gunzinger R, Angelis I. End of the millennium–end of the single thoracic artery graft?. Two thoracic arteries–standard for the next millennium? Early clinical results and analysis of risk factors in 1,487 patients with bilateral internal thoracic artery grafts. J Thorac Cardiovasc Surg 2001;49:10-15.
  10. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Circulation 2004;110:e340-e437.[Free Full Text]
  11. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J Am Coll Cardiol 1999;34:1262-1347.[Free Full Text]
  12. The effect of aggressive lowering of low-density lipoprotein cholesterol levels and low-dose anticoagulant on obstructive changes in saphenous-vein coronary-artery bypass grafts N Engl J Med 1997;336:153-162.[Medline]
  13. Goyal A, Alexander JH, Hafley GE, et al. Outcomes associated with the use of secondary prevention medications after coronary artery bypass graft surgery Ann Thorac Surg 2007;83:993-1001.[Abstract/Free Full Text]
  14. Knatterud GL, Rosenberg Y, Campeau L, et al. Long term effects on clinical outcomes of aggressive lowering of low-density lipoprotein cholesterol levels and low-dose anticoagulation in the Post Coronary Artery Bypass Graft Trial Circulation 2000;102:157-165.[Abstract/Free Full Text]
  15. Mangano DT. Aspirin and mortality from coronary bypass surgery N Engl J Med 2002;347:1309-1317.[Medline]
  16. Ferguson Jr TB, Coombs LP, Peterson ED. Preoperative β-blocker use and mortality and morbidity following CABG surgery in North America JAMA 2002;287:2221-2227.[Abstract/Free Full Text]
  17. Rouleau JL, Warnica WJ, Baillot R, et al. Effects of angiotensin-converting enzyme inhibition in low-risk patients early after coronary artery bypass surgery Circulation 2008;1:24-31117.
  18. Chello M, Anselmi A, Spadaccio C, et al. Simvastatin increases neutrophil apoptosis and reduces inflammatory reaction after coronary surgery Ann Thorac Surg 2007;83:1374-1380.[Abstract/Free Full Text]
  19. Chello M, Mastroroberto P, Patti G, D'ambrosio A, Di Sciascio, Covino E. Simvastatin attenuates leucocyte-endothelial interactions after coronary revascularisation with cardiopulmonary bypass Heart 2003;89:538-543.[Abstract/Free Full Text]
  20. Lazar HL, Bao Y, Zhang Y, Bernard SA. Pretreatment with statins enhances myocardial protection during coronary revascularization J Thorac Cardiovasc Surg 2003;125:1037-1042.[Abstract/Free Full Text]
  21. Domanski M, Tian X, Fleg J, et al. Pleiotropic effect of lovastatin, with and without cholestyramine, in the Post Coronary Artery Bypass Graft (Post CABG) trial Am J Cardiol 2008;102:1023-1027.[Medline]
  22. Kulik A, Brookhart A, Levin R, Ruel M, Solomon D, Choudhry NK. Impact of statin use on outcomes after coronary artery bypass graft Circulation 2008;118:1785-1792.[Abstract/Free Full Text]



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