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

Long-term follow-up after invasive approach of coronary artery disease in daily practice

BACKGROUND

To assess long-term survival in unselected patients with coronary artery disease in who an invasive approach is considered.

METHODS

All patients with significant coronary artery disease who were presented for coronary revascularisation to two tertiary centres in 1992 were included. Follow-up data were collected in September 2002. Multivariate Cox' proportional-hazards regression analysis was applied to assess the independent relation between variables and 10-year survival.

RESULTS

A total of 877 patients were included in this analysis. Mean age was 62 and the most common clinical diagnosis was chronic stable angina (60%). Diabetes was present in 12% of the patients. During the follow-up period, 233 patients (27%) died. Predictors of long-term survival were increasing age, diabetes, peripheral vascular disease and a decreased left ventricular function. Compared to medical treated patients, those treated with revascularisation (either by PCI or CABG) had a decreased long-term mortality (p<0.05). Of the patients with PCI 27% had died, compared to 24% in those who had CABG and 36% of those who were treated medically. However, after adjusting for differences in baseline variables, conservative treatment was no significant predictor of long-term mortality. After multivariable analyses, increasing age, decreased left ventricular function and diabetes were independent predictors of long-term mortality.

CONCLUSIONS

In patients with coronary artery disease in whom an invasive approach is considered, increasing age, impaired left ventricular function and diabetes are the strongest predictors of long-term mortality. After adjustments for differences in baseline variables, invasive treatment is not associated with a lower long-term mortality.

Isolated bypass grafting of the left internal thoracic artery to the left anterior descending coronary artery: late consequences of incomplete revascularization

OBJECTIVE

Multiple strategies to achieve some degree of myocardial revascularization are available. In some, less complete revascularization is accepted to limit invasiveness. To examine the issues of incomplete revascularization, we assessed the long-term impact of additional non-left anterior descending coronary artery stenoses in patients undergoing only grafting of the left internal thoracic artery to the left anterior descending coronary artery.

METHODS

A total of 2067 patients underwent primary isolated grafting of the left internal thoracic artery to the left anterior descending coronary artery from 1971 to 1997. Of these, 26% and 13% had 2- and 3-system disease, respectively. Multivariable analyses of survival and reintervention were performed in the hazard function domain for 27,683 patient-years of follow-up (mean 14 +/- 6.7).

RESULTS

Survival was 99%, 88%, and 62% at 1, 10, and 20 years. Right coronary artery or left circumflex system disease of 50% or more (P =.02) and particularly high-grade (>/=70%) left circumflex (P =.01) and proximal right coronary artery disease (P =.01), as well as any degree of left main trunk stenosis (P <.0001), were associated with reduced long-term survival. Compared with 75% 20-year survival in patients with no non-left anterior descending disease, those with either left circumflex or left main trunk disease experienced a 44% survival, and those with proximal right coronary artery disease, 42%. The most common stated reason for incomplete revascularization was small vessel size. Freedom from reintervention was 89% and 65% at 10 and 20 years, respectively. High-grade left main trunk disease, but, in contrast, mid or distal disease of the right coronary artery, and not left circumflex disease, were risk factors for reintervention.

CONCLUSIONS

These findings call into question the long-term appropriateness of interventions whose strategy includes leaving unrevascularized segments in territories not in the distribution of the left anterior descending coronary artery.

Eight-year mortality in the Emory Angioplasty versus Surgery Trial (EAST)

OBJECTIVES

To evaluate the long-term outcome of patients randomized to coronary bypass surgery or coronary angioplasty.

BACKGROUND

The Emory Angioplasty versus Surgery Trial (EAST) is a single center randomized comparison of a strategy of initial coronary angioplasty (n = 198) or coronary bypass surgery (n = 194) for patients with multivessel coronary artery disease. The primary end point (death, myocardial infarction or a large ischemic defect at 3 years) was not different, and repeat revascularization was significantly greater in the angioplasty group. Subsequently, the National Heart, Lung and Blood Institute supported a five-year extension of the trial.

METHODS

After the three year anniversary visit, annual questionnaires, telephone contact and examination of medical records were accomplished until death or the eight year anniversary in 100% of the patients surviving at 3 years.

RESULTS

Survival at 8 years is 79.3% in the angioplasty group and 82.7% in the surgical group (p = 0.40). Patients with proximal left anterior descending stenosis and those with diabetes tended to have better late survival with surgical intervention although not reaching statistical significance. After the first 3 years, repeat interventions remained relatively equal for both treatment groups.

CONCLUSIONS

Long-term survival is not significantly different between angioplasty and surgery, and late (three to eight year) revascularization procedures were infrequent. Patients without treated diabetes had similar survival in both groups.

Comparison of risk profile and outcomes in patients undergoing surgical and catheter-based revascularization

BACKGROUND

The effects of the randomized revascularization trials and improved strategies and techniques for coronary artery bypass graft (CABG) surgery and percutaneous transluminal catheter-based revascularization (PTCR) on current patient selection and clinical outcomes are unknown.

METHODS

We evaluated a concurrent, contemporary (1995 to 1997), and consecutive group of patients undergoing CABG (n = 982) or PTCR (n = 939) in a single institution that participated in the Bypass Angioplasty Revascularization Investigation (BARI) trial. Results are presented as percent or mean +/- SD. Compared to PTCR, patients undergoing CABG were older (66.2+/-10.7 vs. 62.0+/-11.8 years, p<0.05) with a higher incidence of hypertension (73.3% vs. 52.4%, p<0.05), diabetes (32.5% vs. 23.1%, p<0.05), active smoking (67.8% vs. 27.2%, p<0.05), prior myocardial infarction (MI)(66.8% vs. 28.5%, p<0.05), peripheral vascular disease (19.8% vs. 7.7%, p<0.05), prior cerebrovascular accident (CVA)/transient ischemic attack (TIA) (6.4% vs. 2.8%, p<0.05), and a lower ejection fraction (48.7%+/-14.5% vs. 55.3%+/-11.7%, p<0.05). The presenting functional class and incidence of female gender were similar for both revascularization strategies.

RESULTS

Compared to patients undergoing CABG, those undergoing PTCR were more likely to have single or two vessel coronary artery disease (88.6% vs. 23.1%, p<0.001) and had fewer vessels revascularized per patient (1.08+/-0.30 vs. 3.5+/-0.98, p<0.001). Outcomes were comparable for CABG and PTCR with a similar incidence of death (1.0% vs. 0.9%, NS), renal insufficiency (0.7% vs. 0.6%, NS), and CVA/TIA (0.9% vs. 0.3%, NS). Patients undergoing CABG had a higher incidence of pulmonary complications (5.2% vs. 1.0%, p<0.05), a lower incidence of periprocedural MI (1.1% vs. 4.1%, p<0.05) and major complication (5.9% vs. 9.4%, p<0.05), but longer hospital stays (6.5+/-5.1 vs. 3.1+/-2.6 days, p<0.05).

CONCLUSIONS

Despite higher clinical and angiographic risk profiles in patients undergoing CABG, clinical results, morbidity, and mortality were comparable to those of PTCR. With evolving techniques, continued reevaluation of indications and outcomes are necessary.

Unmet therapeutic needs in the management of acute ischemia

Unstable angina and myocardial infarction (MI) continue to present a major challenge in clinical management. These acute ischemic coronary syndromes (AICS) are a spectrum of clinical presentations of the same pathophysiologic mechanism: thrombus formation superimposed on atherosclerotic plaque disruption or erosion. Current approaches to the management of AICS, which include both interventional and pharmacologic therapy, have been introduced to clinical practice during the past 20 years, and most of them have demonstrated efficacy in clinical studies. A common inadequacy of current therapies, however, is the lack of significant inhibition of platelet aggregation--the crucial event in the formation of coronary thrombi and the pathogenesis of AICS. The final common pathway to platelet aggregation is the activation of the platelet glycoprotein (GP) IIb-IIIa receptor, which allows the cross-linking of adjacent platelets by the adhesive plasma proteins fibrinogen and von Willebrand's factor. The emergence of the GP IIb-IIIa receptor as a potential treatment target has led to the development of several inhibitors of its function. The inhibitors most advanced in clinical development are the chimeric monoclonal antibody abciximab (ReoPro) and the cyclic peptide eptifibatide (INTEGRILIN). In phase III clinical trials, both abciximab and eptifibatide have been shown to reduce the incidence of cardiac events in patients at risk for abrupt vessel closure after coronary angioplasty. Inhibition of the GP IIb-IIIa receptor is the most promising novel approach to the treatment of unstable angina and MI, and it may soon be an indispensable component of the management of patients with AICS.