(Level of Evidence: C) See Online Data Supplement 5 for additional data on CABG in patients with acute myocardial infarction. With the widespread use of fibrinolytic therapy or primary PCI in subjects with STEMI, emergency CABG is now reserved for those with 1) left main and/or 3-vessel CAD, 2) ongoing ischemia after successful or failed PCI, 3) coronary anatomy not amenable to PCI, 4) a mechanical complication of STEMI,241,255,256 and 5) cardiogenic shock (defined as hypotension [systolic arterial pressure 90 mm Hg for 30 minutes or need for supportive measures to maintain a systolic pressure 90 mm Hg], evidence of end-organ hypoperfusion, cardiac index 2.2 L/min/m2 , and pulmonary capillary wedge pressure 15 mm Hg).245,247 In the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial, 36% of patients randomly assigned to early revascularization therapy underwent emer- gency CABG.245 Although those who underwent emergency CABG were more likely to be diabetic and to have complex coronary anatomy than were those who had PCI, the survival rates of the 2 groups were similar.247 The outcomes of high-risk STEMI patients with cardiogenic shock undergoing emergency CABG suggest that CABG may be preferred to PCI in this patient population when complete revasculariza- tion cannot be accomplished with PCI.236,238,246 The need for emergency CABG in subjects with STEMI is relatively uncommon, ranging from 3.2% to 10.9%.257,258 Of the 1572 patients enrolled in the DANAMI-2 (Danish Mul- ticenter Randomized Study on Thrombolytic Therapy Versus Acute Coronary Angioplasty in Acute Myocardial Infarction) study, only 50 (3.2%) underwent CABG within 30 days (30 patients initially treated with PCI and 20 given fibrinolysis), and only 3 patients (0.2%) randomly assigned to receive primary PCI underwent emergency CABG.257 Of the 1100 patients who underwent coronary angiography in the PAMI-2 (Primary Angioplasty in Myocardial Infarction) trial, CABG was performed before hospital discharge in 120.258 The in-hospital mortality rate is higher in STEMI patients undergoing emergency CABG than in those undergoing it on a less urgent or a purely elective basis.239,257,259 264 In a study of 1181 patients undergoing CABG, the in-hospital mortality rate increased as the patients preoperative status worsened, ranging from 1.2% in those with stable angina to 26% in those with cardiogenic shock.265 Although patients requiring emergency or urgent CABG after STEMI are at higher risk than those undergoing it electively, the optimal timing of CABG after STEMI is controversial. 