A randomized trial comparing coronary angioplasty with coronary bypass surgery. Emory Angioplasty versus Surgery Trial (EAST)

Indications for coronary revascularisation: a Dutch perspective

OBJECTIVE

To assess the appropriateness of indications for coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA).

METHODS

A modified Delphi group judgement process with input from a panel of six interventional cardiologists and six cardiopulmonary surgeons. There was one clinician from each of the 12 tertiary referral heart centres in The Netherlands.

MAIN OUTCOME MEASURE

Ratings by panel members, on a 1 to 9 scale, of indications presented as a choice between two treatments (CABG v medical treatment, PTCA v medical treatment, and CABG v PTCA) for 1182 model cases. Each case represented a unique combination of clinical features in terms of symptoms, medical history, and results of tests. Ratings were analysed with respect to degree of agreement among panelists, degree of appropriateness of indications, and panel's preference for invasive or medical treatment.

RESULTS

The panel agreed on 58.6% and disagreed on 3.2% of the indications. The panel opted for invasive treatment in 48.2% and medical treatment in 22.8%, and had no clear preference for either method in 29.0% of the cases. When compared with medical treatment, CABG was more often rated appropriate than PTCA: 35.4% v 21.6% (P < 0.001). Panel scores depended on severity of anatomical disease. For instance, for 51.5% of the model cases with one-vessel disease not including the proximal left anterior descending artery, the panel preferred medical treatment to invasive treatment, while the latter was preferred in 18% of the cases. In cases with type C lesions, the panel frequently rated PTCA as inappropriate. Panel scores were also affected by nonclinical factors. Cardiologists and surgeons rated the procedure of their own specialty higher than the alternative invasive intervention.

CONCLUSIONS

The panel method yields logically consistent scores of the appropriateness of indications for carrying out medical procedures. It may be an aid in formulating clinical practice guidelines.

Outcome of reoperative coronary bypass surgery versus coronary angioplasty after previous bypass surgery

BACKGROUND

The immediate and long-term outcomes of reoperative coronary artery bypass surgery (CABG) (n = 1561) and catheter-based coronary intervention (angioplasty) (n = 2613) were compared in patients from Emory University Hospitals who had previous CABG.

METHODS AND RESULTS

The surgical and angioplasty procedures and statistical methods were standard. Data were collected prospectively and entered into a computerized database. Followup was by letter, telephone, or additional events resulting in readmission. In the angioplasty group, 2.9% required in-hospital CABG. Hospital mortality was 1.2% after angioplasty versus 6.8% after repeat CABG (P < .0001). Recurrent angina was noted frequently at about 4 years and was more common after angioplasty. One-, 5-, and 10-year mortalities were 11%, 24%, and 49% after CABG versus 6%, 22%, and 38% after angioplasty. Survival corrected for baseline differences did not vary with the choice of procedure. There were more additional procedures after angioplasty. Patients undergoing angioplasty may be divided into those with procedures only in native coronary arteries (n = 1545), only in vein grafts (n = 869), and a mixture (n = 199), with respective 10 year survivals of 66%, 56%, and 65% (P < .0001).

CONCLUSIONS

These patients have a high incidence of events both in-hospital and in the long term. Although initial mortality was higher after CABG, after baseline differences were accounted for, there was no difference in the long term. Patients more frequently have additional procedures after angioplasty. Choice of therapy should consider clinical and angiographic suitability and patient preference.

Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery. Bypass Angioplasty Revascularization Investigation (BARI) Investigators

BACKGROUND

Randomized trials comparing coronary angioplasty with bypass surgery in patients with multivessel coronary disease have shown no significant differences in overall rates of death and myocardial infarction. We compared quality of life, employment, and medical care costs during five years of follow-up among patients treated with angioplasty or bypass surgery.

METHODS

A total of 934 of the 1829 patients enrolled in the randomized Bypass Angioplasty Revascularization Investigation participated in this study. Detailed data on quality of life were collected annually, and economic data were collected quarterly.

RESULTS

During the first three years of follow-up, functional-status scores on the Duke Activity Status Index, which measures the ability to perform common activities of daily living, improved more in patients assigned to surgery than in those assigned to angioplasty (P<0.05). Other measures of quality of life improved equally in both groups throughout the follow-up period. Patients in the angioplasty group returned to work five weeks sooner than did patients in the surgery group (P<0.001). The initial mean cost of angioplasty was 65 percent that of surgery ($21,113 vs. $32,347, P<0.001), but after five years the total medical cost of angioplasty was 95 percent that of surgery ($56,225 vs. $58,889), a difference of $2,664 (P = 0.047). The five-year cost of angioplasty was significantly lower than that of surgery among patients with two-vessel disease ($52,930 vs. $58,498, P<0.05), but not among patients with three-vessel disease ($60,918 vs. $59,430). After five years of follow-up, surgery had an overall cost-effectiveness ratio of $26,117 per year of life added, but unacceptable ratios of $100,000 or more per year of life added could not be excluded (P=0.13). Surgery appeared particularly cost effective in treating diabetic patients because of their significantly improved survival.

CONCLUSIONS

In patients with multivessel coronary disease, coronary-artery bypass surgery is associated with a better quality of life for three years than coronary angioplasty, after the initial morbidity caused by the procedure. Coronary angioplasty has a lower five-year cost than bypass surgery only in patients with two-vessel coronary disease.

Recent progress in coronary interventions--assessment by quantitative coronary angiography

Coronary balloon angioplasty is now well accepted as an effective therapy for patients with significant coronary artery stenosis. However, a number of deficiencies, including short-term complications, long-term restenosis, and limited application to complex morphologic lesions, restrict the widespread use of this technique. The precise lesion measurement provided by quantitative coronary angiography and intracoronary ultrasonography is a prerequisite for the optimization of balloon dilation or stent implantation. The short-term outcome may be improved by stent implantation, as this can prevent acute closure by acting as a scaffold for the disrupted vessel wall. The indications for percutaneous revascularization have been extended to chronic total occlusion by using a special guidewire, a laser wire and a coronary stent. Local drug delivery techniques to distribute agents to target revascularization sites may play a role in reducing the restenosis rate. Although the limitations of balloon angioplasty have led to the introduction of new devices, it remains to be seen whether these new devices can demonstrate, in a scientific manner, their safety, feasibility and superiority over conventional balloon angioplasty. Percutaneous coronary revascularization therapy may be an acceptable alternative to coronary bypass surgery in the future. However, to confirm this, a large multicenter randomized study is necessary to compare new percutaneous coronary interventional devices with bypass surgery. Additionally, further studies are required to demonstrate the most effective device for treating specific lesions in each individual patient.

Thrombolytic therapy for patients with prior percutaneous transluminal coronary angioplasty and subsequent acute myocardial infarction. GUSTO-I Investigators. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries

Our purpose was to evaluate the outcomes of patients with prior coronary angioplasty who underwent thrombolysis for new acute myocardial infarction (AMI) in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries-I trial. Baseline characteristics and clinical outcomes were compared between patients with (n = 1,647) and without (n = 39,150) previous angioplasty. The relations among prior angioplasty, clinical outcomes, and treatment effects were examined with logistic regression modeling. Patients with previous angioplasty tended to be younger and presented sooner after symptom onset, but had more multivessel disease and lower ejection fractions. Unadjusted mortality was significantly lower in the prior-angioplasty group at 24 hours (1.8% vs 2.7%, p = 0.03) and 30 days (5.6% vs 7.0%, p = 0.036). Although most of the survival advantage was due to low-risk characteristics in this group (lower age and heart rate and fewer anterior wall AMIs), prior angioplasty remained a weak but independent predictor of survival. Recurrent ischemia and reinfarction occurred more often in the prior-angioplasty group, as did bypass surgery (12.2% vs 8.5%) and repeat angioplasty (34.5% vs 21.4%). Patients with prior angioplasty and prior AMI had lower 30-day mortality than those with prior infarction alone (6.3% vs 12.6%, p < 0.01). Treatment effects on 30-day mortality were similar among patients with prior angioplasty (odds ratio 1.2 for accelerated tissue-plasminogen activator v. combined streptokinase arms, 95% confidence interval 0.73 to 1.9). Patients with prior angioplasty who present with AMI have fewer in-hospital adverse events and lower 30-day mortality than those without such a history.

Long-term outcome of percutaneous transluminal coronary angioplasty and coronary bypass surgery for multivessel coronary artery disease

We studied the short- and long-term outcomes of 97 patients treated with percutaneous transluminal coronary angioplasty (PTCA) and 72 patients treated with coronary artery bypass graft surgery (CABG) for multivessel coronary artery disease in a single hospital in 1989. Patients treated with CABG had a higher angina class, a higher incidence of diabetes mellitus and a greater extent of the disease. Complete revascularization was achieved in 61 patients (85%) with CABG and in 45 patients (46%) with PTCA (p < 0.001). Initial success of PTCA and CABG was obtained in 95% and 94% of the patients with PTCA and CABG, respectively. Actuarial survival rates at 5 years were similar (96% in the PTCA group; 94% in the CABG group). Fewer patients suffered from cardiac death or myocardial infarction in the CABG group than in the PTCA group, but this difference was not significant. The rate of survival free from death, myocardial infarction, CABG and repeat PTCA, was significantly higher in the CABG group than in the PTCA group (85% vs 48%; p < 0.001). These results suggest that CABG provides a favorable long-term outcome in patients with multivessel coronary artery disease and that PTCA provides a similar outcome in these patients when applied to suitable lesions, although more patients who undergo PTCA require repeat procedures.

Clinical significance of perioperative Q-wave myocardial infarction: the Emory Angioplasty versus Surgery Trial

OBJECTIVE

The primary end point of the Emory Angioplasty versus Surgery Trial was a composite of three events: death, Q-wave infarction, and a new large defect on 3-year postoperative thallium scan. This study examines the clinical significance of Q-wave infarction in the surgical cohort (194 patients) of the Emory trial.

METHODS

Twenty patients (10.3%) with Q-wave infarctions were identified: 13 patients had inferior Q-wave infarctions and seven patients had anterior, lateral, septal, or posterior Q-wave infarctions (termed anterior Q-wave infarctions).

RESULTS

In the inferior Q-wave infarction group, postoperative cardiac catheterization (at 1 year or 3 years) in 11 patients revealed normal ejection fraction (ejection fraction >55%) in 10 (91%), no wall motion abnormalities in 10 (91%), and all grafts patent in 10 (91%). In the anterior Q-wave infarction group, postoperative catheterization in six patients revealed normal ejection fractions in five (83%), no wall motion abnormalities in three (50%), and all grafts patent in three (50%). Average peak postoperative creatine kinase MB levels were as follows: no Q-wave infarction (n = 174) 37 +/- 43 IU/L, inferior Q-wave infarction 40 +/- 27 IU/L, and anterior Q-wave infarction 58 +/- 38 IU/L. Mortality in the 20 patients with Q-wave infarctions was 5% (1/20) at 3 years; in patients without a Q-wave infarction it was 6.3% (11/174) (p = 0.64). Of 17 patients with a Q-wave infarction who underwent postoperative catheterization, 11 (65%) had a normal ejection fraction, normal wall motion, and all grafts patent with an uneventful 3-year postoperative course.

CONCLUSIONS

The core laboratory screening of postoperative electrocardiograms, particularly in the case of inferior Q-wave infarctions, appears to identify a number of patients as having a Q-wave infarction with minimal clinical significance. Q-wave infarction identified in the postoperative period seems to be a weak end point with little prognostic significance and therefore not valuable for future randomized trials.

Coronary angioplasty versus repeat coronary artery bypass grafting for patients with previous bypass surgery

OBJECTIVES

We attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG).

BACKGROUND

Due to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG.

METHODS

We retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%).

RESULTS

Complete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group.

CONCLUSIONS

In this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.

Evaluating the cost of therapy for restenosis: considerations for brachytherapy

Costs have become increasingly important in medicine in recent years as demand for services has outstripped readily available resources. Clinical microeconomics offers an approach to understanding cost and outcomes in an environment of economic scarcity. In this article the types of costs and methods for determining cost are presented. In addition, methods for assessing outcome and outcome in relation to cost are developed. Restenosis after coronary angioplasty is a prime example of a clinical problem requiring economic evaluation. This is because it results in little serious morbidity except for recurrent chest pain, but it has serious economic consequences which occur some time after the original angioplasty. This makes the economic assessment of restenosis complicated. The application of health care microeconomic principles to brachytherapy for restenosis in the coronary arteries is presented.

Use of coronary artery bypass surgical procedure and coronary angioplasty in treatment of coronary artery disease: changes during a 10-year period at Mayo Clinic Rochester

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.

"Keyhole" coronary artery bypass surgery

OBJECTIVE

The objective of this study was to identify the utility of "keyhole" thoracotomy approaches to single vessel coronary artery bypass surgery.

SUMMARY BACKGROUND DATA

Although minimally invasive surgery is efficacious in a wide variety of surgical disciplines, it has been slow to emerge in cardiac surgery. Among 49 selected patients, the authors have used a left anterior keyhole thoracotomy (6 cm in length) combined with complete dissection of the eternal mammary artery (IMA) pedicle under thoracoscopic guidance or directly through the keyhole incision to accomplish IMA coronary artery bypass grafting (CABG) to the left anterior descending (LAD) coronary artery circulation or to the right coronary artery (RCA).

METHODS

Keyhole CABG was accomplished in 46 of 49 patients in which this approach was attempted. All patients had significant (> 70%) obstruction of a dominant coronary artery that had failed or that was inappropriate for endovascular catheter treatment (percutaneous transluminal coronary angioplasty or stenting). Forty-four of the 49 patients had proximal LAD and 5 had proximal RCA stenoses. The mean age of the patients (35 men and 14 women) was 61 years, and their median New York Heart Association anginal class was III. The mean left ventricular ejection fraction was 42%. Femoral cardiopulmonary bypass support was used in 9 (19%) of 46 patients successfully managed with the keyhole procedure. Short-acting beta-blockade was used in the majority of patients (38 of 46) to reduce heart rate and the vigor of cardiac contraction.

RESULTS

As 49 patients have survived operation, which averaged 248 minutes in duration. Median, postoperative endotracheal intubation time for keyhole patients was 6 hours with 25 of 46 patients being extubated before leaving the operating room. The median hospital stay was 4.3 days. Conversion to sternotomy was required in three patients to accomplish bypass because of inadequate internal mammary conduits or acute cardiovascular decompensation during an attempted off-bypass keyhole procedure Postoperative complications were limited to respiratory difficulty in three patients and the development of a deep wound infection in one patient. Nine (19%) of 46 patients received postoperative transfusion. There have been no intraoperative or postoperative infarctions, and angina has been controlled in all but one patient who subsequently had an IMA-RCA anastomotic stenosis managed successfully with percutaneous transluminal coronary angioplasty.

CONCLUSIONS

These early results with keyhole CABG are encouraging. As experience broadens, keyhole CABG may become a reasonable alternative to repeated endovascular interventions or sternotomy approaches to recalcitrant single-vessel coronary arterial disease involving the proximal LAD or RCA.

Contemporary practice of coronary revascularization in U.S. hospitals and hospitals participating in the bypass angioplasty revascularization investigation (BARI)

OBJECTIVES

To assess generalizability of the Bypass Angioplasty Revascularization Investigation (BARI), we conducted a separate study comparing revascularization in U.S. and BARI hospitals.

BACKGROUND

The BARI trial is a multicenter investigation comparing initial revascularization with percutaneous transluminal coronary angioplasty and coronary bypass graft surgery in patients with symptomatic multivessel coronary disease.

METHODS

All revascularization procedures during 5 consecutive workdays were surveyed at 75 U.S. hospitals offering coronary angioplasty and bypass surgery and at all BARI hospitals. Data collected were demographics, extent of disease and type of current and previous revascularization.

RESULTS

At both U.S. and BARI hospitals, 57% of all revascularization procedures were coronary angioplasty and 43% were bypass surgery. The U.S. hospitals had more patients with single-vessel disease, acute myocardial infarction and primary procedures. Other characteristics were similar. The majority of revascularization procedures were angioplasty for single-vessel disease (U.S. 32% vs. BARI 25%) and bypass surgery for triple-vessel disease (U.S. 31% vs. BARI 31%). Overall, the choice between bypass surgery and angioplasty was similar in BARI and U.S. hospitals (adjusted odds ratio [OR] 1.0, p = 0.914). However, older patients were more likely and younger patients less likely to undergo bypass surgery in BARI versus U.S. hospitals (older patients: adjusted OR 1.6, p = 0.031; younger patients: adjusted OR 0.6, p = 0.028). The BARI protocol would have excluded 65% of all candidates for revascularization, for whom indications already exist for angioplasty or bypass surgery, and another 23%, for whom angioplasty would be contraindicated for individual lesions.

CONCLUSIONS

Patients undergoing coronary revascularization in BARI and U.S. hospitals were generally similar, as was the choice between types of revascularization. Results from the BARI trial apply to approximately 300 (12%) candidates for coronary revascularization/workday.

Current incidence and determinants of perioperative myocardial infarction in coronary artery surgery

Increasingly, patients undergoing coronary artery bypass grafting (CABG) are elders, have had previous CABG, and have poor left ventricular function. To evaluate determinants of perioperative myocardial infarction (PMI) after isolated CABG, 499 consecutive patients were reviewed. Definite PMI (total peak creatine kinase [CK] > 700 U/L, creatine kinase MB [CK-MB] > 30 ng/ml, and new pathologic electrocardiographic Q waves) occurred in 25 patients (5.0%) and probable PMI (total peak CK > 700 U/L, CK-MB > 30 ng/ml, and a new wall-motion abnormality) occurred in 10 (2.0%) patients. According to multivariate logistic regression analysis, independent risk factors for definite or probable PMI (adds ratios; 95% confidence intervals) were emergency surgery (3.1; 1.1 to 8.4; p = 0.003), aortic cross-clamp time > 100 minutes (4.2; 1.6 to 11.2; p = 0.004), myocardial infarction in the preceding week (2.6; 1.0 to 6.4; p = 0.04), and previous revascularization (2.4; 1.1 to 5.2; p = 0.02). In conclusion, both preoperative and intraoperative factors influence the risk of PMI after CABG. Despite changes in the profile of patients undergoing CABG, the incidence of PMI in this tertiary center is comparable with that found in earlier series, probably because of improvements in surgical techniques and postoperative care.

Cost-effectiveness of routine coronary angiography after acute myocardial infarction

BACKGROUND

Coronary angiography is indicated for many patients after acute myocardial infarction (AMI). There are a number of subgroups of AMI patients, however, for whom the indication for coronary angiography is not well established.

METHODS AND RESULTS

We developed a decision-analytic model for AMI in representative patient subgroups based on relevant clinical characteristics. The model estimates quality-adjusted life expectancy and direct lifetime costs for two strategies: coronary angiography and treatment guided by its results versus initial medical therapy without angiography. Decision tree chance node probabilities were estimated with the use of pooled data from randomized clinical trials and other relevant literature, costs were estimated with the use of the Medicare Part A database, and quality of life adjustments were derived from a survey of 1051 patients who had had a recent AMI. In our analysis, incremental cost-effectiveness ratios for coronary angiography and treatment guided by its result, compared with initial medical therapy without angiography, ranged between $17,000 and > $1 million per quality-adjusted year of life gained. Patient subgroups with severe postinfarction angina or a strongly positive exercise tolerance test (ETT) typically had cost-effectiveness ratios of < $50,000 per quality-adjusted year of life gained. In addition, most patient subgroups with a prior AMI had cost-effectiveness ratios of < $50,000 per quality-adjusted year of life gained, even with a negative ETT result.

CONCLUSIONS

In many patient subgroups after AMI, the cost-effectiveness of routine coronary angiography and treatment guided by its results compares favorably with other treatment strategies for coronary heart disease.

Indications, practice, and procedural outcomes of percutaneous transluminal coronary angioplasty in northern New England in the early 1990s. The Northern New England Cardiovascular Disease Study Group

We conducted a prospective cohort study from October 1, 1989 to December 31, 1993 of the current indications, practices and procedural outcomes of percutaneous transluminal coronary angioplasty (PTCA) in Northern New England to determine how it compared with reports from other regions and registries. Thirty-five cardiologists contributed data on 12,232 admissions for PTCA performed at all hospitals in New Hampshire and Maine, plus 1 in Massachusetts, supporting PTCA. Mean patient age was 61.1 years, 67.5% were men, and 38.5% had multivessel disease. Unstable (45.6%), stable (22.9%), and postinfarction angina (21.0%) were common indications for the procedure. Of all patients, 86.9% had 1-vessel PTCA, including 65.7% of those with multivessel disease. Angiographic success was 90.4%, and 88.1% of patients had > or = 1 lesion successfully dilated and no adverse clinical event. The risk of death, nonfatal acute myocardial infarction, or coronary artery bypass grafting was 5.7%. The practice and outcomes of PTCA in Northern New England were somewhat similar to reports from other regional registries but different from a registry of select institutions. We conclude that PTCA as performed in Northern New England is safe and effective.

The importance of completeness of revascularization during long-term follow-up after coronary artery operations

Completeness of revascularization after coronary artery bypass operation has been shown to improve short- and medium-term outcome. The purpose of this study was to assess the independent contribution of completeness of revascularization to long-term outcome. A total of 2057 patients with multivessel disease with complete revascularization and 803 with incomplete revascularization, mean age 57 +/- 9 years, was studied. The patient groups were similar except for more prior myocardial infarctions, worse left ventricular function, and more three-vessel disease in the incomplete revascularization group. Complications of perioperative infarction and stroke were not different between those having complete versus incomplete revascularization. The hospital death rate for patients having complete revascularization during the period of study was 0.7% versus 1.5% for those having incomplete revascularization (p = 0.06). Length of hospital stay for the two groups of patients also was not different. At late follow-up (mean 11.7 years for complete and 10.8 years for incomplete) patients who had incomplete revascularization had a significantly higher prevalence of recurrent angina. Multivariate analysis demonstrated the strongest predictors of incomplete revascularization to be number of vessels diseased and left ventricular function (ejection fraction). The multivariate correlates of survival were older age, left ventricular dysfunction, and completeness of revascularization. Completeness of revascularization correlated with improved overall patient survival, as well as survival in patients with normal left ventricular function. Furthermore, the curves continued to separate over time, such that the difference was greater at 8 years than at 4 years, although by 12 years the curves started to converge.

Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease

BACKGROUND

Coronary-artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are alternative methods of revascularization in patients with coronary artery disease. We tested the hypothesis that in selected patients with multivessel disease suitable for treatment with either procedure, an initial strategy of PTCA does not result in a poorer five-year clinical outcome than CABG.

METHODS

Patients with multivessel disease were randomly assigned to an initial treatment strategy of CABG (n = 914) or PTCA (n = 915) and were followed for an average of 5.4 years. Analysis of outcome events was performed according to the intention to treat.

RESULTS

The respective in-hospital event rates for CABG and PTCA were 1.3 percent and 1.1 percent for mortality, 4.6 percent and 2.1 percent for Q-wave myocardial infarction (P < 0.01), and 0.8 percent and 0.2 percent for stroke. The five-year survival rate was 89.3 percent for those assigned to CABG and 86.3 percent for those assigned to PTCA (P = 0.19; 95 percent confidence interval of the difference in survival, -0.2 percent to 6.0 percent). The respective five-year survival rates free from Q-wave myocardial infarction were 80.4 percent and 78.7 percent. By five years after study entry, 8 percent of the patients assigned to CABG had undergone additional revascularization procedures, as compared with 54 percent of those assigned to PTCA; 69 percent of those assigned to PTCA did not subsequently undergo CABG. Among diabetic patients who were being treated with insulin or oral hypoglycemic agents at base line, a subgroup not specified by the protocol, five-year survival was 80.6 percent for the CABG group as compared with 65.5 percent for the PTCA group (P = 0.003).

CONCLUSIONS

As compared with CABG, an initial strategy of PTCA did not significantly compromise five-year survival in patients with multivessel disease, although subsequent revascularization was required more often with this strategy. For treated diabetics, five-year survival was significantly better after CABG than after PTCA.

Quality of life, employment status, and anginal symptoms after coronary angioplasty or bypass surgery. 3-year follow-up in the Randomized Intervention Treatment of Angina (RITA) Trial

BACKGROUND

The Randomized Intervention Treatment of Angina (RITA) trial compares initial policies of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG) in 1011 patients with angina. This report assesses the impact of these revascularization procedures on angina, quality of life (according to the Nottingham Health Profile), and employment over 3 years of follow-up.

METHODS AND RESULTS

Both interventions produced marked improvement in all quality-of-life dimensions (energy, pain, emotional reactions, sleep, social isolation, and mobility) and seven aspects of daily living. Patients with angina at 2 years had more quality-of-life impairment than angina-free patients, whose perceived health was similar to population norms. This reflects the close link at baseline between angina grade and quality of life. The slightly greater impairment of quality of life in PTCA compared with CABG patients is a result of their significantly higher chances of having angina, especially after 6 months. Employment status was investigated mainly for men < or = 60 years old. PTCA patients returned to work sooner (40% at 2 months compared with 10% of CABG patients), but the latter caught up by 5 months. After 2 years, 22% and 26% of CABG and PTCA patients, respectively, were not working for cardiac reasons. Patients with angina at 2 years were much more likely to be unemployed than those without.

CONCLUSIONS

The impact of angina on quality of life and unemployment is greatly alleviated by PTCA or CABG. Angina is avoided more successfully with CABG, but PTCA offers a speedier return to work. Both intervention strategies then produce similar benefits for quality of life and employment over several years.

PTCA with the use of cardiac assist devices: risk stratification, short- and long-term results

Percutaneous cardiopulmonary assist devices (PCPS) have become available in interventional cardiology within recent years. These tools offer the opportunity of performing percutaneous transluminal coronary angioplasty (PTCA) in high-risk patients characterized by significant stenoses of several coronary arteries and a poor left ventricular function. It is unclear for which patients PCPS are necessary and which patients will profit by PTCA as compared to coronary artery bypass grafting (CABG). Therefore, the anticipated risk of CABG and of PTCA without assist devices was calculated according to risk scores and compared with our results of assisted PTCA. In addition the long-term survival rate was investigated. In 35 patients (mean 65.5 years of age, 12 females, 23 males), we performed PTCA concomitant with the use of cardiac assist devices. The indications for the use of a cardiac assist device were severely impaired LV function (EF 30% +/- 8.9%) in combination with significant coronary artery disease (2.7 +/- 0.3 vessels) and a significant supply area of the vessel to be dilated. In 6 patients, PCPS was started before coronary angioplasty because of hemodynamic instability. In 21 cases, PCPS was on a standby basis without being connected to the patient's circulation. In 8 patients, a left heart assist device, the 14F-Hemopump, was inserted percutaneously. The patients were analyzed using risk scores of angioplasty and of coronary bypass graft surgery. The calculated risk of hemodynamic compromise during PTCA according to the risk scores was more than 50%. The anticipated risk of a fatal outcome following CABG would have been 19.8%. PTCA was performed on an average of 2.0 coronary arteries per patient and was successful in 85%. We observed a decline in angina pectoris classification (CCS) from 3.5 to 1.6. An average reduction of 1.1 NYHA class was achieved. The in-hospital mortality was 8.6% (3 patients: 1 x sepsis, 1 x early reocclusion, 1 x cerebral embolism). At 24 months follow-up, a re-PTCA was necessary in four cases because of restenosis. In the remainder, NYHA and CCS class were stable during the follow-up period. An additional five patients died during the first year and two patients in the second year. We conclude that PTCA with the use of a cardiac assist device shows favorable short-term results in a subset of patients with extended coronary artery disease and severely impaired LV function who are not suitable for nonsupported PTCA or CABG due to their risk profile. However, the long term results are not satisfying and stress the need for complete revascularisation with CABG once the patient's condition is stabilized by means of supported PTCA.

Clinical outcome 10 years after attempted percutaneous transluminal coronary angioplasty in 856 patients

OBJECTIVES

This study reports the 10-year outcome of 856 consecutive patients who underwent attempted coronary angioplasty at the Thoraxcenter during the years 1980 to 1985.

BACKGROUND

Coronary balloon angioplasty was first performed in 1977, and this procedure was introduced into clinical practice at the Thoraxcenter in 1980. Although advances have been made, extending our knowledge of the long-term outcome in terms of survival and major cardiac events remains of interest and a valuable guide in the treatment of patients with coronary artery disease.

METHODS

Details of survival, cardiac events, symptoms and medication were retrospectively obtained from the Dutch civil registry, medical records or by letter or telephone or from the patient's physician and entered into a dedicated data base. Patient survival curves were constructed, and factors influencing survival and cardiac events were identified.

RESULTS

The procedural clinical success rate was 82%. Follow-up information was obtained in 837 patients (97.8%). Six hundred forty-one patients (77%) were alive, of whom 334 (53%) were symptom free, and 254 (40%) were taking no antianginal medication. The overall 5- and 10-year survival rates were 90% (95% confidence interval [CI] 87.6% to 92.4%) and 78% (95% CI 75.0% to 81.0%), respectively, and the respective freedom from significant cardiac events (death, myocardial infarction, coronary artery bypass surgery and repeat angioplasty) was 57% (95% CI 53.4% to 60.6%) and 36% (95% CI 32.4% to 39.6%). Factors that were found to adversely influence 10-year survival were age > or = 60 years (> or = 60 years [67%], 50 to 59 years [82%], < 50 years [88%]), multivessel disease (multivessel disease [69%], single-vessel disease [82%]), impaired left ventricular function (ejection fraction < 50% [57%], > or = 50% [80%]) and a history of previous myocardial infarction (previous myocardial infarction [72%], no previous infarction [83%]). These factors were also found to be independent predictors of death during the follow-up period by a multivariate stepwise logistic regression analysis. Other factors tested, with no influence on survival, were gender, procedural success and stability of angina at the time of intervention.

CONCLUSIONS

The long-term prognosis of patients after coronary angioplasty is good, particularly in those <60 years old with single-vessel disease and normal left ventricular function. The majority of patients are likely to experience a further cardiac event in the 10 years after their first angioplasty procedure.

Effectiveness of revascularization in the Emory angioplasty versus surgery trial. A randomized comparison of coronary angioplasty with bypass surgery

BACKGROUND

The Emory Angioplasty Versus Surgery Trial (EAST) was designed to determine whether percutaneous transluminal coronary angioplasty (PTCA) is as effective as coronary artery bypass graft surgery (CABG) in restoring arterial perfusion capacity in eligible patients with multivessel disease.

METHODS AND RESULTS

Of 392 patients in EAST, 198 were randomized to PTCA and 194 to CABG. Index lesions (2.7 +/- 1.0 per patient) were those with > or = 50% stenosis judged treatable by both angioplasty and surgery. Coronary segments jeopardized by these index lesions were designated as index segments (4.4 +/- 1.4 per patient). Percent stenosis was measured by quantitative angiography at the point of greatest obstruction in the main perfusion path of each index segment. The EAST primary arteriographic end point was the percent of a patient's index segments with < 50% stenosis in the main perfusion pathways at 1 and 3 years. At baseline, the percent of index segments for which revascularization was attempted was 85% for PTCA and 98% for CABG (P < .0001). At 1 year, PTCA patients had a smaller percentage of successfully revascularized index segments than CABG patients (59% versus 88%, P < .001). At 3 years, the findings were similar but less striking (70% versus 87%, P < .001). When only "high-priority" index segments (2.1 +/- 1.6 per patient) were considered, baseline attempts were comparable (96% versus 99%, P = NS); despite this, CABG remained more successful at 1 (64% versus 93%, P < .001) and 3 (76% versus 89%, P < .01) years. However, the mean percent of index segments free of severe stenosis (> or = 70%) did not differ between PTCA and CABG patients at 3 years (93% versus 95%, P = NS). Furthermore, the frequency of patients with all index segments free of severe stenosis did not differ between the two groups at 1 (76% versus 83%, P = NS) or 3 (82% for both PTCA and CABG) years.

CONCLUSIONS

In patients with multivessel disease, index segment revascularization was more complete with CABG than PTCA at both 1 and 3 years. However, when the physiological priority of the target lesion and the measured severity of the residual stenosis are taken into account, the advantage of CABG becomes less significant or nonsignificant. This may, in part, explain why these two strategies did not differ in terms of the EAST primary clinical end points over 3 years.

Cost-effective management of chronic stable angina

In certain patients with stable angina who are at moderate to high risk, coronary bypass surgery or coronary angioplasty are the therapeutic options of choice. However, in selected other patients the use of anti-ischemic drug therapy and secondary prevention reduce episodes of myocardial ischemia and result in a good long-term prognosis. Factors affecting management include the extent of coronary disease, the magnitude of cardiac symptoms, the severity of myocardial ischemia and of left ventricular function. Based upon these and other clinical characteristics, patients can be divided into low-, moderate-, or high-risk categories for morbidity and mortality. Patients at high risk are more likely to be selected for myocardial revascularization and patients at low risk are often treated with medical therapy, at least initially. Based on the available cost-effectiveness data, medical therapy or coronary angioplasty are the preferred initial strategies for low-risk coronary disease, whereas coronary bypass surgery (CABG) is recommended for many high-risk patients, particularly for those with triple-vessel disease and impaired left ventricular function or ischemia at a low workload. CABG is cost-effective for patients with severe angina and left main coronary artery disease and also for patients with mild angina and triple-vessel disease. Coronary angioplasty is cost-effective for patients with severe angina, and single- or multivessel disease. In patients with lesser symptoms and mild coronary disease, the cost effectiveness of myocardial revascularization therapy is less likely to be as good as it is in patients with more extensive disease and severe symptoms.

Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease

The purpose of this study was to evaluate long-term survival benefits of bypass surgery and angioplasty versus medical therapy in 9263 patients at Duke University Medical Center between 1984 and 1990 with coronary artery disease confirmed by cardiac catheterization to involve one, two, or three vessels. Clinical data were prospectively entered into an established cardiovascular database, and annual follow-up was 97% complete for a mean interval of 5.3 years and a maximal interval of 10 years. Outcomes were analyzed with the Coronary Artery Surgery Study "method A" to define patient groups treated by medicine (n = 2449), angioplasty (n = 2924), or bypass surgery (n = 3890). Differences among treatment groups in baseline characteristics were adjusted by Cox proportional hazard models. The anatomic severity of coronary artery stenosis best defined survival benefit from bypass surgery and angioplasty versus medical treatment. One or both interventional treatments provided better long-term survival than did medical treatment for all levels of disease severity. All patients with single-vessel disease, except those with at least 95% proximal left anterior descending stenosis, benefited from angioplasty versus bypass. All patients with three-vessel disease and those two-vessel patients with > or = 95% proximal left anterior descending stenosis benefited from bypass surgery versus angioplasty. All other patients with two-vessel disease and those with > or = 95% proximal left anterior descending stenosis only had similar survival with either interventional treatment. The absolute survival benefit was greatest for patients with severe three-vessel disease treated with bypass surgery.

Restenosis--an open file

The main procedural drawback to percutaneous coronary angioplasty is restenosis of the treated site within 6 months. Despite advances in equipment, technique, and adjunctive therapies, restenosis has occurred in approximately one-third to one-half of all patients. The biology of restenosis can be divided into plaque persistence and recoil, thrombus formation and transformation, and cellular proliferation and vascular remodeling. Animal models of restenosis have helped to elucidate these mechanisms of restenosis and provide a means to test pharmacologic and mechanical strategies to reduce stenosis recurrence. While numerous agents have been tested in animal models, until recently none has translated into benefit in large-scale clinical trials. Two therapeutic "hopefuls" which have recently emerged in clinical practice are the potent platelet inhibitors, glycoprotein IIb/IIIa receptor antagonists, and intracoronary metallic stents. The IIb/IIIa receptor antagonists target thrombus formation at the angioplasty site, thereby minimizing abrupt vessel closure acutely and neointimal growth chronically, while intracoronary stents safely produce a large coronary arterial lumen acutely and prevent vessel recoil. Separately, these therapeutic strategies have been shown to reduce clinical restenosis 20-30% at 6-month follow-up. With these encouraging results, the future will certainly provide more pharmacologic and mechanical therapies targeting restenosis. With increased understanding of the restenotic process and continued refinement of effective treatments, it may be possible one day to prevent stenosis recurrence.

Long-term results after successful percutaneous transluminal coronary angioplasty in patients over 75 years of age

A prospective study comparing the long-term results of balloon angioplasty in patients over 75 years of age with those in a younger patient group is not available. A total of 192 consecutive patients aged > or = 75 years (group I) who underwent a balloon angioplasty were matched with 192 control patients aged 40 to 65 years (group II). The groups were matched for gender, angina pectoris class, left ventricular function, 1-, 2-, and 3-vessel coronary artery disease, and previous myocardial infarction. The mean follow-up was 40.4 months (range 0 to 110). Actuarial analysis (freedom from events) after 5 years yielded the following results for group I versus group II: free from death remained 77.1% versus 97.9% (p = 0.0001), from cardiac death 92.4% versus 97.9% (p = 0.049), and from angina pectoris 54.6% versus 75.1% (p = 0.03). The differences were not significant for those remaining free from myocardial infarction, repeat balloon angioplasty, or coronary artery bypass grafting. When elderly patients with complete revascularization (n = 127) were compared with a matched control group of 127 patients aged 40 to 65 years who underwent complete revascularization, there was only a significant difference in noncardiac death rates. We conclude that patients > 75 years of age have a significant higher cardiac and noncardiac death rate and a higher incidence of angina pectoris after successful balloon angioplasty. However, the incidence of reintervention and myocardial infarction is lower in the elderly. If complete revascularization is achieved in the elderly, then freedom from cardiac death and recurrence of angina pectoris would be comparable to that in younger patients.

Three-year follow-up of the Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease (ERACI)

OBJECTIVES

The purpose of this study was to report the 3-year follow-up results of the ERACI trial (Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease).

BACKGROUND

Although coronary angioplasty has been used with increased frequency in patients with multivessel coronary artery disease, its value, compared with bypass graft surgery, has not been established. Thus, controlled, randomized clinical trials such as the ERACI are needed.

METHODS

In this trial 127 patients who had multivessel coronary artery disease and clinical indication of myocardial revascularization were randomized to undergo coronary angioplasty (n = 63) or bypass surgery (n = 64). The primary end point of this study was event-free survival (survival with freedom from myocardial infarction, angina and new revascularization procedures) for both groups of patients at 1, 3 and 5 years of follow-up.

RESULTS

Freedom from combined cardiac events (death, Q-wave myocardial infarction, angina and repeat revascularization procedures) was significantly greater for the bypass surgery group than the coronary angioplasty group (77% vs. 47%; p < 0.001). There were no differences in overall (4.7% vs. 9.5%; p = 0.5) and cardiac (4.7% vs. 4.7%; p = 1) mortality or in the frequency of myocardial infarction (7.8% vs. 7.8%; p = 0.8) between the two groups. However, patients who had bypass surgery were more frequently free of angina (79% vs. 57%; p < 0.001) and required fewer additional reinterventions (6.3% vs. 37%; p < 0.001) than patients who had coronary angioplasty.

CONCLUSIONS

1) Freedom from combined cardiac events at 3-year follow-up was greater in patients who had bypass surgery than in those who had coronary angioplasty. 2) The coronary angioplasty group had a higher incidence of recurrence of angina and the need for repeat revascularization procedures. 3) Cumulative cost at 3-year follow-up was greater for the bypass surgery group than for the coronary angioplasty group.

Port-access coronary artery bypass grafting: a proposed surgical method

Minimally invasive surgical methods have been developed to provide patients the benefits of open operations with decreased pain and suffering. We have developed a system that allows the performance of cardiopulmonary bypass and myocardial protection with cardioplegic arrest without sternotomy or thoracotomy. In a canine model, we successfully used this system to anastomose the internal thoracic artery to the left anterior descending coronary artery in nine of 10 animals. The left internal thoracic artery was dissected from the chest wall, and the pericardium was opened with the use of thoracoscopic techniques and single lung ventilation. The heart was arrested with a cold blood cardioplegic solution delivered through the central lumen of a balloon occlusion catheter (Endoaortic Clamp; Heartport, Inc., Redwood City, Calif.) in the ascending aorta, and cardiopulmonary bypass was maintained with femorofemoral bypass. An operating microscope modified to allow introduction of the 3.5x magnification objective into the chest was positioned through a 10 mm port over the site of the anastomosis. The anastomosis was performed with modified surgical instruments introduced through additional 5 mm ports. In the cadaver model (n = 7) the internal thoracic artery was harvested and the pericardium opened by means of similar techniques. A precise arteriotomy was made with microvascular thoracoscopic instruments under the modified microscope on four cadavers. In three other cadavers we assessed the exposure provided by a small anterior incision (4 to 6 cm) over the fourth intercostal space. This anterior port can assist in dissection of the distal internal thoracic artery and provides direct access to the left anterior descending, circumflex, and posterior descending arteries. We have demonstrated the potential feasibility of grafting the internal thoracic artery to coronary arteries with the heart arrested and protected, without a major thoracotomy or sternotomy.

Care of acute myocardial infarction by noninvasive and invasive cardiologists: procedure use, cost and outcome

OBJECTIVES

This study sought to determine how noninvasive and invasive cardiologists may differ in the hospital care of patients with acute myocardial infarction.

BACKGROUND

Scant information exists regarding the effect of noninvasive and invasive cardiology subspecialization on invasive cardiac procedural use, cost and outcome in the care of patients with acute myocardial infarction.

METHODS

This study analyzed a prospective cohort of 292 patients admitted to an urban tertiary care hospital from the emergency room under the care of noninvasive or invasive cardiologists. Clinical characteristics; hospital course, including management, utilization of diagnostic coronary angiography and percutaneous transluminal coronary angioplasty; direct hospital costs; length of hospital stay; and post-hospital discharge follow-up data were collected by a prospective data base instrument.

RESULTS

Despite similar clinical characteristics, extent and severity of coronary artery disease and utilization of diagnostic coronary angiography in the two groups of patients, those under the care of an invasive cardiologist were significantly more likely to undergo coronary angioplasty than those under the care of a noninvasive cardiologist. The direct hospital costs and length of stay of the noninvasive and invasive group patients who underwent coronary angioplasty were similar, although overall the direct hospital costs and length of stay were higher for the invasive than for the noninvasive group patients.

CONCLUSIONS

Noninvasive and invasive cardiologists differ in their rate of utilization of coronary angioplasty in similar patients with acute myocardial infarction.

Analysis of costs associated with CABG and PTCA

BACKGROUND

Factors related both to the patient and to the healthcare provider affect the costs of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). The costs of both PTCA and CABG are most highly dependent on the occurrence of complications in the postprocedure period. Costs are lower in centers that have adequate procedure volumes, due partly to economics of scale and partly to improved outcomes.

METHODS

The relative costs of PTCA and CABG in patients suitable for either procedure is being investigated in several ongoing randomized clinical trials. The cost-effectiveness of coronary revascularization relative to medical therapy has also been investigated. The cost-effectiveness of PTCA relative to medical therapy has not been evaluated.

RESULTS

The initial cost of PTCA is roughly half that of CABG, but costs are similar after 2- or 3-year follow-up because of the need for repeat revascularization procedures in patients initially treated with PTCA. The data on cost-effectiveness of coronary revascularization relative to medical therapy have shown that CABG is particularly cost-effective in patients for whom survival is improved or in whom symptoms of severe angina are relieved.

CONCLUSIONS

Percutaneous transluminal coronary angioplasty and CABG are costly but effective therapies. Clearly PTCA costs less initially but the follow-up costs are much higher. The cost-effectiveness of coronary revascularization can be improved by maintaining adequate procedural volumes, reducing procedural complications, and selecting patients properly.

Costs of coronary restenosis (Lovastatin Restenosis Trial)

Within the Lovastatin Restenosis Trial, restenosis has been clearly shown to increase resource utilization and costs. While it is not possible to generalize these results to other patient populations, it is clear that successful efforts to decrease restenosis will certainly improve efficacy while decreasing follow-up costs and increasing the cost-effectiveness of intervention in the coronaries.

The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses

OBJECTIVES

This study sought to evaluate, in a prospective and randomized trial, the relative efficacies of three possible therapeutic strategies for patients with a single severe proximal stenosis of the left anterior descending coronary artery and stable angina.

BACKGROUND

Although percutaneous transluminal coronary angioplasty and coronary artery bypass surgery are often performed in patients with a single proximal stenosis of the left anterior descending coronary artery, it is unclear whether revascularization offers greater clinical benefit than medical therapy alone.

METHODS

At a single center, 214 patients with stable angina, normal ventricular function and a proximal stenosis of the left anterior descending coronary artery > 80% were randomly assigned to undergo mammary bypass surgery (n = 70), balloon angioplasty (n = 72) or medical therapy alone (n = 72). Angioplasty had to be considered technically feasible in every case. The predefined primary study end point was the combined incidence of cardiac death, myocardial infarction or refractory angina requiring revascularization.

RESULTS

At an average follow-up period of 3 years, a primary end point had occurred in only 2 patients (3%) assigned to bypass surgery compared with 17 assigned to angioplasty (24%) and 12 assigned to medical therapy (17%) (p = 0.0002, angioplasty vs. bypass surgery; p = 0.006, bypass surgery vs. medical treatment; p = 0.28, angioplasty vs. medical treatment, all by log-rank test). There was no difference in mortality or infarction rates among the groups. However, no patient allocated to bypass surgery needed revascularization, compared with eight and seven patients assigned, respectively, to coronary angioplasty and medical treatment (p = 0.019). Both revascularization techniques resulted in greater symptomatic relief and a lower incidence of ischemia on the treadmill test; however, all three strategies eventually resulted in the abolition of limiting angina.

CONCLUSIONS

The more aggressive therapeutic approach with initial bypass surgery for patients with a single severe proximal stenosis of the left anterior descending coronary artery is associated with a lower incidence of medium-term adverse events than coronary angioplasty or medical treatment. However, all three strategies resulted in a similar incidence of death and infarction during an average follow-up period of 3 years. This information should be taken into consideration when physicians and patients make therapeutic choices in this setting.

Effect of the increasing use of coronary angioplasty on outcome at one year in patients with unstable angina

OBJECTIVE

To determine whether the increasing use of percutaneous transluminal angioplasty in patients with unstable angina has reduced the need for bypass surgery and whether this change in the choice of treatment affected the outcome at one year in patients with unstable angina who were admitted to hospital in two different periods of time.

DESIGN

Retrospective analysis of consecutive patients with unstable angina (angina at rest with ST-T changes during pain) who underwent coronary arteriography in two different periods of time.

PATIENTS

158 patients were admitted to hospital between January 1988 and June 1989 (group 1) and 140 patients admitted between January 1992 and June 1993 (group 2).

RESULTS

Coronary angioplasty procedures nearly doubled from 29% in group 1 to 56% in group 2 whereas bypass surgery decreased from 36% in group 1 to 23% in group 2 (P < 0.01). Coronary angioplasty increased and bypass surgery decreased in patients with one vessel disease (P < 0.01), two vessel disease (P < 0.05), and three vessel disease (P < 0.01). Coronary angioplasty also increased and bypass surgery decreased in refractory angina and in patients with ejection fraction < 0.50 (both P < 0.05). At 1-year follow up, 14 patients in group 1 (9%) and 10 in group 2 (7%) either died or had myocardial infarction (P = NS). Revascularisation procedures were needed in 16 group 1 patients (10%) and 27 group 2 patients (19%, P < 0.05).

CONCLUSIONS

Coronary angioplasty became more widely used in patients with unstable angina. This reduced the need for bypass surgery in patients with multivessel disease, refractory angina, and depressed left ventricular function. This change in treatment did not affect 1-year mortality or the myocardial infarction rate. More patients in the more recent group in which angioplasty was the preferred treatment required a further revascularisation procedure than in the earlier group in which bypass grafting was more often used as the initial treatment.

A comparison of the costs of and quality of life after coronary angioplasty or coronary surgery for multivessel coronary artery disease. Results from the Emory Angioplasty Versus Surgery Trial (EAST)

BACKGROUND

The Emory Angioplasty Versus Surgery Trial (EAST) is a randomized trial that compares, by intention to treat, the clinical outcome and costs of percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery for multivessel coronary artery disease.

METHODS AND RESULTS

The primary end point was a composite of death, Q-wave myocardial infarction, and a large reversible thallium defect at 3 years. Multiple measures of quality of life also were made. Charges were assessed from the hospital UB-82 bills; professional charges were assessed from the Emory Clinic. Hospital charges were reduced to cost through step-down accounting methods. All costs and charges were deflated to 1987 dollars. Costs were assessed for the initial hospitalization and the cumulative costs of the initial hospitalization and additional revascularization procedures for up to 3 years. There was no difference in mortality or the primary end point. Mean initial hospital charges were $12,654 for the PTCA group and $20,214 for the surgery group (P < .0001). Professional charges were 4538 for PTCA and $9426 for surgery (P < .0001). Three-year hospital charges were $19,047 for PTCA and $21,174 for coronary surgery (P < .0001). Three-year professional charges were $6412 for PTCA and $9861 for surgery (P < .0001). Three-year total charges were $25,458 for PTCA and $31,033 for surgery (P < .0001). Total 3-year costs were $23,734 for PTCA and $25,310 for coronary surgery (P < .0001). There were more hospitalizations for angina and more antianginal medications used in the PTCA group, which would further narrow the differences in cost.

CONCLUSIONS

There was no difference in the primary end point or its components at 3 years. Although the primary procedural costs of coronary surgery are more than for coronary angioplasty, this cost advantage is largely, although probably not completely, lost by 3 years because of more frequent additional procedures and other resource consumption after a first revascularization by PTCA.