Coronary Artery Surgery is Favoured Over Medical Therapy In patients with impaired left ventricular function and at least one proximal obstruction ...

The value of coronary artery bypass surgery In pat ients with coronary artery disease is controversial. To address this issue, 2023 pat ients from 15 centres participated In a non-randomised triai designed to compare the effects of coronary artery bypass graft surgery and medical therapy on survival in patients with severe angina pectoris and ~ 70% stenosIs In 2 major epicardial arteries . Patients received either medical therapy (n = 706) or underwent coronary artery bypass graft surgery (1317) and were followed for up to 6 years .

The 6-year cumulative survival rate was significantly higher in surgically-treated patients than in patients receiving medical therapy (89 vs 76%: p < 0.0001) . There were no significant differences between the 2 treatment groups in patients with normal left ventricular function and with 0, 1 or 2 proximal obstructions . Likewise , there was no between-group difference in the 6-year survival rate in patients who had mild to moderate left ventricular dysfunction without any proximal obstruction However, in patients with 1 or 2 proximal obstructions and mild to moderate left ventricular dysfunction, the survival rate was better with surgical treatment than with medical therapy (89 vs 74%: p < 0.0001 and 85 vs 71 % , P < 00027, respectively) Among the patients with severe angina, 2-vessel disease and severe left ventricular dysfunction the survival rate was significantly higher In patients receiving surgical treatment than in those receiving medical therapy (78 vs 49%)

The authors concluded that ' ... although medical versus surgical comparisons for the total group of patients with 2-vessel disease and severe angina show a small but statistically significant difference in favour of surgery, . .. this advantage for the surgical patients is confined to those with impaired L V [leN ventricular} function and at least 1 significant proximal obstruction'. Mock MB, F,sher LD. Holmes DR, Gersh BJ. Schaff HV, et al American Journal of CardIOlogy 61 1198-1203, Jun 1988

... and in patients with angina at rest and 3-vessel disease A stud y was conducted to compare the effect of surgical and medical treatment on the long term

prognosIs of 400 patients complaining of angina at rest associated with transient repolarlsation changes Patients received nitrates (generally nitroglycerin 15-20mg qid as ointment) , jj-blockers (generally propranolol ) and calCium antagonists (generally nlfediplne 10-20mg qid) (n = 215) or underwent surgery Within 90 days after cardiac catheterisation (185)

There were 22 cardiac deaths in the medically-treated group compared with 19 In the surgically­treated group There was no significant difference between the 2 treatment groups In the 5-year survival rate . Left ventricular end diastolic pressure , age of > 45 years and the number of diseased vessels were identified as independent predictors of patient prognosis (p < 0001 . p < 0.05 and p < 0.05,

respectively) . Among the patients With 3-vessel disease only. surgical therapy resulted In a significantly (p < 005) better long term outcome than did medical therapy

The authors concluded that ' ... surgery does not prolong survival In aI/ patients with angina at rest associated with transient repolarlzatlon changes. However, patients with three-vessel disease have a better prognosis If treated surglcal/y'.

De Servo S. BerZUlno C. Ghoa S. FerrarIO M. Poma E. et aJ European Heart Journal 9: 513-519, May 1988 7413

01562703/ 88/ 0813·0007/ 0$0100/ 0 ([) ADIS Press INPHARMA 13 Aug 1988 7