RESUMEN

BACKGROUND: The influence of age on the relative success of either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients requiring myocardial revascularization continues to be controversial. METHODS: In the Bypass Angioplasty Revascularization Investigation (BARI) trial, 1,829 patients with symptomatic multivessel coronary artery disease requiring revascularization were randomly assigned to undergo either CABG or PTCA. RESULTS: Seven hundred nine patients (39%) were 65 to 80 years old at baseline; the other 1,120 were younger than 65 years. The in-hospital 30-day mortality rate for PTCA and CABG in the younger patients was 0.7% and 1.1%, respectively, and that for patients 65 years or older was 1.7% and 1.7%, respectively. In older compared with younger patients, stroke was more common after CABG (1.7% versus 0.2%, p = 0.015) and heart failure or pulmonary edema was more common after PTCA (4.0 versus 1.3%, p = 0.011). In both age groups, CABG resulted in greater relief of angina and fewer repeat procedures. The 5-year survival rate in patients younger than 65 years was 91.5% for CABG and 89.5% for PTCA. In patients 65 years or older, the 5-year survival rate was 85.7% for CABG and 81.4% for PTCA. Cardiac mortality at 5 years was greater in patients assigned to the PTCA group than in those assigned to the CABG group. However, no significant treatment differences were noted in cardiac mortality when only nondiabetic patients were examined. CONCLUSIONS: Within the context of the Bypass Angioplasty Revascularization Investigation trial, older patients with multivessel coronary disease do well with either PTCA or CABG. Compared with younger patients, older patients had less recurrent angina and were less likely to undergo repeat procedures, particularly among those assigned to undergo CABG. Cardiac mortality was greater in patients 65 years or older assigned to undergo PTCA; however, this difference was not noted when treated diabetic patients were excluded from analysis.

Asunto(s)

RESUMEN

BACKGROUND: Numerous studies have shown that women undergoing coronary revascularization procedures do so at a higher risk for an adverse outcome compared with men. However, the impact of advances in technology and improvements in techniques on in-hospital and long-term outcome after revascularization in women is unclear. METHODS AND RESULTS: We evaluated 1829 patients with symptomatic multivessel coronary disease randomized to CABG or PTCA in the Bypass Angioplasty Revascularization Investigation (BARI), of whom 27% were women. As expected, women were older (64.0 versus 60.5 years), with more congestive heart failure (14% versus 7%), hypertension (68% versus 42%), treated diabetes mellitus (31% versus 15%), and unstable angina (67% versus 61%) than men but had similar preservation of left ventricular function and extent of multivessel disease. Women assigned to surgery received the same number of total grafts but fewer internal mammary artery grafts (72% versus 85%, P<0. 01), and those assigned to angioplasty had more intended lesions (76% versus 71%, P<0.01) successfully dilated than men. At an average of 5.4 years' follow-up, crude mortality rates were similar in women (12.8%) and men (12.0%). The Cox regression model adjusting for baseline differences revealed that women had a significantly lower risk of death (relative risk, 0.60; 95% CI, 0.43 to 0.84; P=0. 003) but not a significantly lower risk of death plus myocardial infarction (relative risk, 0.84; 95% CI, 0.66 to 1.07; P=0.16) than men. CONCLUSIONS: Although the unadjusted mortality rate suggests that women and men undergoing CABG and PTCA have a similar 5-year mortality, women have higher risk profiles; consequently, contrary to previous reports, female sex is an independent predictor of improved 5-year survival after we control for multiple risk factors.

Asunto(s)

RESUMEN

OBJECTIVE: To compare changing clinical characteristics and early and late outcomes for patients treated with either coronary artery bypass grafting or coronary angioplasty at Mayo Clinic Rochester during a 10-year period. DESIGN: We retrospectively analyzed a series of patients with coronary artery disease who were clinically selected for myocardial revascularization from Jan. 1, 1982, through Dec. 31, 1991. MATERIAL AND METHODS: The study population consisted of 7,099 patients treated with coronary artery bypass grafting and 4,937 who underwent coronary angioplasty. To monitor changes in clinical and procedural outcomes over time, we divided the 10-year period into three equal intervals: period I = Jan. 1, 1982, through Apr. 30, 1985; period II = May 1, 1985, through Aug. 31, 1988; and period III = Sep. 1, 1988, through Dec. 31, 1991. Patients who underwent valve or arrhythmia operations along with coronary bypass were excluded from the study, as were those who were treated with angioplasty technologies other than balloon angioplasty. RESULTS: Throughout the study period, use of coronary angioplasty progressively increased (784 procedures in period I and 3,516 in period III). The number of coronary bypass operations increased from period I to period II but declined in period III. Over time, increasing numbers of elderly patients and women were referred for myocardial revascularization. Use of the internal mammary artery as a bypass conduit increased from 23% of cases in period I to 84% in period III. In surgical patients, perioperative myocardial infarction rates declined significantly from 5.7% to 2.0% from periods I to III. For coronary angioplasty, elderly patients, patients with diabetes, and patients with hypertension progressively increased. Multivessel coronary angioplasty increased from 10% of the cases in period I to 15% in period III. Operative mortality rates for both coronary bypass and angioplasty remained stable throughout the study despite the increasing number of high-risk patients. CONCLUSION: This 10-year experience with coronary bypass and angioplasty at a major referral center reflects the national trend of an aging patient population with coronary artery disease undergoing revascularization procedures.

Asunto(s)

RESUMEN

OBJECTIVES: This study sought to determine whether in-hospital and intermediate-term posthospital outcomes have changed in elderly patients undergoing percutaneous transluminal coronary angioplasty from the period 1980 through 1989 to the period 1990 through 1992. BACKGROUND: Although elderly patients have a higher incidence of procedure-related deaths and late recurrence of angina after coronary angioplasty, recent complication rates for angioplasty seem to be lower. METHODS: From 1980 to 1989, 982 patients > or = 65 years old underwent nonemergent coronary angioplasty (group A). They were compared with 768 similar patients who had coronary angioplasty from 1990 to 1992 (group B). RESULTS: Patients in group B were older than those in group A and had a higher mean concomitant disease score, a higher proportion of men and a greater proportion of patients with a previous myocardial infarction and previous coronary artery bypass surgery. Despite the increased complexity of the group B cohort, procedural success rates were higher, and rates of important in-hospital complications were much lower than those in group A. For group A versus group B, respectively, the technical success rate was 88.1% versus 93.5% (p < 0.001), in-hospital death rate 3.3% versus 1.4% (p = 0.014), emergency bypass surgery rate 5.5% versus 0.65% (p < 0.001) and incidence of in-hospital death or myocardial infarction 6.3% versus 3.4% (p < 0.005). However, intermediate-term posthospital event-free rates in hospital survivors did not decrease. The rate of death or myocardial infarction at 6 months was 4.7% in group A versus 7.1% in group B (p < 0.05). Survival free of acute myocardial infarction, bypass surgery, repeat coronary angioplasty or severe angina at 1 year was 66.7% in group A versus 54.9% in group B (p < 0.001). The combined in-hospital death/myocardial infarction rate plus that for the first 6 months after hospital dismissal was essentially equivalent for the two groups (10.3% vs. 9.9%, p = NS). CONCLUSIONS: An increase in technical success rates and a reduction in short-term complication rates for coronary angioplasty in the elderly in recent years have not translated into an improved event-free survival rate, which continues to be influenced by important baseline characteristics of these high risk patients.

Asunto(s)

RESUMEN

This report presents baseline clinical and angiographic data from the Bypass Angioplasty Revascularization Investigation (BARI), a multicenter international trial assessing the relative efficacy of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft surgery (CABG) in selected patients with multivessel coronary artery disease. PTCA is commonly performed in patients with multivessel coronary artery disease, yet its long-term efficacy in comparison to CABG is unknown. From August 1988 through August 1991, 1,829 qualifying patients with multivessel disease suitable for either procedure were randomized to PTCA or CABG; sample size estimates were based on anticipated 5-year mortality. Two registry populations were also defined for follow-up: (1) 2,013 patients eligible for randomization but not randomized; and (2) 422 patients considered by angiography as unsuitable for randomization. Patients randomized in BARI were at relatively high risk for subsequent cardiac events: 39% were > or = 65 years old, 55% had prior myocardial infarction, 69% presented with unstable angina or non-Q wave myocardial infarction, and 43% had 3-vessel coronary artery disease. Patients randomized to PTCA and CABG were equally matched in all the important baseline variables. The randomized and the eligible but not randomized groups were similar in most respects. However, the nonrandomized group had a higher proportion with college education; fewer with a history of myocardial infarction, heart failure, diabetes, and smoking; and a somewhat better average ejection fraction. At the 3-month follow-up, PTCA had been performed more commonly in the nonrandomized eligible patients, especially those with 2-vessel disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Asunto(s)

RESUMEN

BACKGROUND: This study describes the impact of clinical, angiographic, and demographic characteristics on the long-term survival of Coronary Artery Surgery Study (CASS) patients while they were under medical treatment. Revascularization rates for the population are also provided. METHODS AND RESULTS: All CASS patients who had not received heart surgery before enrollment (23,467 patients) were included in this survival analysis while they were under medical treatment or surveillance. Follow-up time ranged from 0 to 17 years (median, 12 years). Long-term vital status is known for 95.8% of these patients. Log-rank tests, Kaplan-Meier survival curves, and Cox proportional-hazards regression are used to describe and assess the impact of patient characteristics on survival. Characteristics that had a significant impact on survival, in order of observed explanatory power, are age, number of diseased vessels, congestive heart failure score, smoking history, ejection fraction, sex, presence of left main coronary artery disease, presence of diabetes, left ventricular wall motion score, presence of other illnesses, history of myocardial infarction, and presence of left main equivalent disease. Overall, 12-year survival for patients with zero-, one-, two- and three-vessel disease is 88%, 74%, 59%, and 40%, respectively. Twelve-year survival for patients with at least one diseased vessel and ejection fractions in the ranges of 50% to 100%, 35% to 49%, and 0% to 34% is 73%, 54%, and 21%, respectively. High myocardial jeopardy, high anginal class, and two or three proximal diseased vessels characterize the profile of patients most likely to have received surgical treatment during follow-up. CONCLUSIONS: These results contribute to the understanding of the natural history of coronary artery disease and are also of historical interest. The poor survival of patients with three-vessel disease and low ejection fractions continues to emphasize the importance of considering revascularization for these patients.

Asunto(s)

RESUMEN

Five hundred thirty-six residents of Olmsted County, Minnesota, who underwent supine rest and exercise radionuclide angiography because of known or suspected coronary artery disease, were followed for a median of 46 months to determine the prognostic value of exercise radionuclide angiography in a community population who generally did not undergo coronary angiography. There were 71 persons who experienced a new cardiac event (the initial events were cardiac death and nonfatal myocardial infarction in 26 and 45 persons, respectively). A proportional-hazards model identified 4 independent predictors of cardiac events: exercise ejection fraction (p < 0.001), exercise heart rate (p < 0.001), and age (p = 0.04). Four-year infarct-free survival was 98% for the 152 patients with a peak exercise heart rate at or above the median (122 beats/min) and an exercise ejection fraction at or above the median (0.58). In the 150 patients with a peak exercise heart rate < 122 beats/min and an exercise ejection fraction < 0.58, 4-year infarct-free survival was 68%. When this population-based cohort was compared with a referral case series previously reported from our institution, these population-based patients were significantly more likely to be men, to have typical angina, to have higher exercise heart rates and exercise ejection fractions, and were less likely to be receiving beta-receptor antagonist therapy. At each level of exercise ejection fraction, the population-based patients had a slightly but insignificantly greater risk than referral patients for subsequent cardiac events. These population-based data provide strong evidence of the prognostic value of exercise radionuclide angiography in community practice.

Asunto(s)

RESUMEN

Using data from the Coronary Artery Surgery Study (CASS) registry, we evaluated the relationship between cholesterol levels measured at enrollment and the following events: all-cause mortality, cardiac death, fatal myocardial infarction (MI), and nonfatal MI. Only patients with a significant coronary artery disease (at least one lesion with stenosis > or = 50%) were considered for this study. Results presented for mortality are for a period of up to 11.5 years and those for MI are for a maximum of 8 years of follow-up. Analyses were performed for each type of event and for each subgroup: women (n = 1861) and men (n = 10,941) under age 65, and women (n = 426) and men (n = 1144) age 65 or older. After adjusting for important covariates, cholesterol level was not associated with cardiac or all-cause mortality. No relationship between cholesterol level and fatal or nonfatal MI could be demonstrated except for men under age 65. However, in this subgroup the risk of MI was highest for those with low or middle cholesterol levels. The data show that in patients with angiographically determined coronary artery disease, cholesterol level is not a statistically significant risk factor for death or MI over the follow-up period in CASS.

Asunto(s)

RESUMEN

The immediate and long-term efficacy of coronary angioplasty in the elderly was determined by studying 752 patients greater than or equal to 65 years old and comparing patients greater than or equal to 75 years old with those 65 to 74 years old. The oldest patients were more highly symptomatic, were more likely to be in heart failure, had more multivessel disease and were more likely to undergo multivessel dilation. The immediate success rate of angioplasty was higher in the oldest patients (92.8% versus 82%) (p = 0.0003). The hospital mortality rate was also higher (6.2% versus 1.6%) (p less than 0.001). Long-term overall survival was high. However, long-term event-free survival was lowest in the oldest patients, and recurrent severe angina was particularly common. Thus, in very elderly patients, coronary angioplasty is usually successful, but extra caution is warranted; also, long-term relief from angina is less common than in younger patients.

Asunto(s)

RESUMEN

The Coronary Artery Surgery Study (CASS) randomized 780 patients to an initial strategy of coronary surgery or medical therapy. Of medically randomized patients, 6% had surgery within 6 months and a total of 40% had surgery by 10 years. At 10 years, there was no difference in cumulative survival (medical, 79% vs. surgical, 82%; NS) and no difference in percentage free of death and nonfatal myocardial infarction (medical, 69% vs. surgical, 66%; NS). Patients with an ejection fraction of less than 0.50 exhibited a better survival with initial surgery treatment (medical, 61% vs. surgical, 79%; p = 0.01). Conversely, patients with an ejection fraction greater than or equal to 0.50 exhibited a higher proportion free of death and myocardial infarction with initial medical therapy (medical, 75% vs. surgical, 68%; p = 0.04) although long-term survival remained unaffected (medical, 84% vs. surgical, 83%; p = 0.75). There were no significant differences either in survival and freedom from nonfatal myocardial infarction, whether stratified on presence of heart failure, age, hypertension, or number of vessels diseased. Thus, 10-year follow-up results confirm earlier reports from CASS that patients with left ventricular dysfunction exhibit long-term benefit from an initial strategy of surgical treatment. Patients with mild stable angina and normal left ventricular function randomized to initial medical treatment (with an option for later surgery if symptoms progress) have survival equivalent to those patients randomized to initial surgery.

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

We examined survival rates during a 6-year follow-up of patients in the registry of the Coronary Artery Surgery Study who had three vessel coronary artery disease and Canadian Cardiovascular Society class III-IV angina pectoris. All patients had a stenosis of 70% or greater in either the mid or proximal segment of all three coronary arteries. There were 679 medically treated patients and 1921 surgically treated patients in this nonrandomized comparison. Patients were stratified by left ventricular wall motion score and number of proximal coronary artery stenoses; after adjustment for these variables, the estimated probability of being alive at 6 years was 82% for surgically treated patients and 59% for medically treated patients (p less than 0.0001). Among patients with the most severe left ventricular dysfunction (left ventricular wall motion score of 16 to 30), the 6-year survival rate was 63% for surgically treated patients and 30% for medically treated patients (p less than 0.0001). Those with three proximal lesions (all gradations of left ventricular score) had an 81% 6-year survival rate with surgical treatment and 40% with medical treatment (p less than 0.0001). Ninety percent of surgically treated patients with normal ventricular function were living at 6 years and 78% of medically treated patients (p less than 0.0001). Among these patients, the survival rate was significantly better after surgical treatment than after only medical treatment if two or three proximal stenoses were present. If no proximal lesions were present (all categories of left ventricular function), 84% of surgically treated patients and 67% of medically treated patients were alive at 6 years (p less than 0.0001). In a multivariate (Cox) analysis of preoperative clinical, hemodynamic, and angiographic factors, early operation was a strong predictor of survival (estimated relative risk 0.38).

Asunto(s)

RESUMEN

Identification of patients at risk of sudden death is essential if optimal preventive treatment strategies are to be developed. In the Coronary Artery Surgery Study (CASS) Registry, 19,946 patients were analyzed to characterize baseline clinical, hemodynamic and angiographic features of patients dying from sudden cardiac death and to compare them with features of patients dying from other cardiac causes, of those dying from noncardiac causes and of survivors. Of the 11,843 medically treated patients, 1,621 died during a mean follow-up period of 5.0 years: death was sudden in 557 (34%), nonsudden but cardiac in 813 (50%) and noncardiac in 251 (16%). In 8,103 surgically treated patients, 824 deaths occurred during a mean follow-up period of 5.1 years: death was sudden in 204 (25%), nonsudden but cardiac in 390 (47%) and noncardiac in 230 (28%). In general, the patients (both medically and surgically treated) who died of cardiac causes, either suddenly or nonsuddenly, were similar to each other but significantly different from patients who either survived or died of noncardiac causes. Although patients with an increased risk of any type of cardiac death could be identified, there were no measures of angiographic or hemodynamic characteristics that were significantly different between patients with sudden cardiac death and those with nonsudden cardiac death. Identification of patients at high risk for sudden cardiac death will require approaches in addition to clinical, angiographic and hemodynamic assessment, such as electrophysiologic assessment or monitoring techniques to identify triggering mechanisms.

Asunto(s)

RESUMEN

The goal of thrombolytic treatment in acute myocardial infarction is to reestablish permanent blood flow, salvage ischemic myocardium, and reduce mortality. If patency is achieved sufficiently early and is maintained, left ventricular function is preserved and mortality decreases. The recent experience with tissue plasminogen activator and streptokinase in the TIMI I trial is reviewed with specific attention to reperfusion, reocclusion, and bleeding. Other studies concerning left ventricular preservation and mortality are also discussed. Current guidelines for antithrombotic therapy and thrombolysis are discussed. It is extremely important to adequately select patients to avoid side effects. Thorough lysis of the thrombus must be achieved to reduce the risk of rethrombosis. Simultaneous heparin should be administered to treat ongoing thrombosis. Additional antithrombotic therapy with aspirin and acute vasodilation to reduce vasoconstriction probably also decrease the likelihood of reocclusion. Because this treatment predisposes to bleeding, extreme care should be taken to avoid vascular punctures and invasive procedures in these patients. The association of immediate percutaneous transluminal coronary angioplasty has not been beneficial in preventing further events; on the contrary, adverse effects have been associated with this acute intervention.

Asunto(s)

RESUMEN

This nonrandomized study compared the results of early coronary artery bypass grafting to those of initial medical therapy in a group of 2,023 patients with severe angina pectoris and 2 major epicardial coronary arteries having greater than or equal to 70% diameter luminal narrowing. Medical therapy was selected for 706 patients, and 1,317 patients were treated by coronary artery bypass grafting. The 6-year survival rate was 76% for patients treated medically and 89% for patients treated surgically (p less than 0.0001). Cox multivariate analysis showed that surgical treatment was a beneficial independent predictor of survival (p less than 0.001). For patients with 2-vessel coronary artery disease who had Canadian Heart Association class III and IV angina at presentation, surgical therapy provided a survival advantage for patients with impaired left ventricular function and proximal narrowing of 1 or more coronary arteries.

Asunto(s)

RESUMEN

We compared time to first new myocardial infarction during a 6-year follow-up in patients in the registry of the Coronary Artery Surgery Study who had three-vessel coronary artery disease and Canadian Cardiovascular Society Class III-IV angina pectoris. There were 679 medically treated patients and 1921 surgically treated patients in this nonrandomized comparison. A broad definition of myocardial infarction incorporating electrocardiographic and clinical criteria was used to include as many new infarctions as possible. Patients were stratified by left ventricular wall motion score and number of proximal coronary artery stenoses; after adjustment for these variables, 86% of surgical and 73% of medical patients were free of new myocardial infarction at 6 years (p less than 0.0001). This advantage of surgical treatment was observed in subgroups of patients with at least one proximal 70% (or greater) stenosis in the left anterior descending coronary artery and moderate or severe impairment of left ventricular function, as well as those patients with two proximal coronary artery narrowings. In a multivariate (Cox) analysis of preoperative clinical, hemodynamic, and angiographic factors, early operation was the strongest predictor of freedom from new myocardial infarction.

Asunto(s)

RESUMEN

This is an extensive review of thrombolysis in myocardial infarction with discussions of the pathophysiology of occlusion, clinical occlusion and rationale for thrombolysis, thrombolytic agents, results of thrombolysis (incidence of reperfusion, left ventricular function, and mortality), complications of thrombolytic therapy, reocclusion, and current recommendations.

Asunto(s)

RESUMEN

Results of coronary artery bypass grafting were evaluated in 856 nonrandomized patients in the Coronary Artery Surgery Study (CASS) registry with mild angina (Canadian Cardiovascular Society Classes I and II) and three-vessel disease, defined as 70% or more stenosis in the proximal or middle segment of the three major coronary arteries. There were 413 patients with medical therapy and 443 with early operation. Patients with delayed operation were kept in the medical group for analysis. Six-year survival adjusted for left ventricular (LV) function and number of proximal stenoses was 67% for medical and 84% for surgical patients (p less than 0.0001). Patients with normal LV function had equal survival with medicine or surgical intervention. Those with mild or moderate LV dysfunction (CASS LV wall motion score 6 to 9 and 10 to 15, respectively) and at least one proximal stenosis (the dominant right coronary artery) had increased probability of being alive at six years with surgical treatment. In patients with severe LV impairment (LV score higher than 15) and in those whose only proximal stenosis of 70% or more (in three-vessel disease) was located in the left anterior descending coronary artery, increased survival with surgical treatment could not be demonstrated. This is a nonrandomized observational study with the limitations of such studies: the need to adjust for differences in baseline traits between medical and surgical groups and the possibility of an unrecognized imbalance in baseline characteristics. In a Cox analysis of variables influencing outcome, early surgical treatment was an independent predictor of survival with 43% the risk of medical treatment (95% confidence range: 29 to 62%). Adjustment by propensity analysis to reduce selection bias from known differences in baseline variables did not alter results.

Asunto(s)