The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the extent of coronary disease.This study sought to determine whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial.Baseline SYNTAX scores were retrospectively calculated for BARI-2D patients without prior revascularization (N = 1,550) by angiographic laboratory investigators masked to patient characteristics and outcomes. The primary outcome was major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years.A mid/high SYNTAX score (≥23) was associated with a higher risk of major cardiovascular events (hazard ratio: 1.36, confidence interval: 1.07 to 1.75, p = 0.01). Patients in the CABG stratum had significantly higher SYNTAX scores: 36% had mid/high SYNTAX scores compared with 13% in the PCI stratum (p < 0.001). Among patients with low SYNTAX scores (≤22), major cardiovascular events did not differ significantly between revascularization and medical therapy, either in the CABG stratum (26.1% vs. 29.9%, p = 0.41) or in the PCI stratum (17.8% vs. 19.2%, p = 0.84). Among patients with mid/high SYNTAX scores, however, major cardiovascular events were lower after revascularization than with medical therapy in the CABG stratum (15.3% vs. 30.3%, p = 0.02), but not in the PCI stratum (35.6% vs. 26.5%, p = 0.12).Among patients with diabetes and stable ischemic heart disease, higher SYNTAX scores predict higher rates of major cardiovascular events and were associated with more favorable outcomes of revascularization compared with medical therapy among patients suitable for CABG. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes; NCT00006305).

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%o 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%o vs. surgical, 66%; NS). Patients with

To examine whether digitalis use is associated with an increased mortality in certain highrisk subsets of patients with coronary artery disease, we analyzed the data of 14,547 patients in the Coronary Artery Surgery Study (CASS) registry who had significant coronary artery stenosis (¢ 70% narrowing) and received medical treatment for their disease. At the time of entry, 2600 patients (18%) Were taking a digitalis preparation. At a mean follow-up of 41/2 years, the cumulative mortality rate for these patients was 18%, compared with 5% for the 11,947 patients not taking digitalis (p < 0.001). Univariate analysis showed significant differences between the two groups in the following baseline variables: prior infarction, multiple infarction, age, degree of congestive heart failure (CHF), extent of disease, cardiomegaly and wall motion abnormalities. Cox regression analysis of the entire population failed to show digitalis to be one of the 13 variables independently predictive of survival. High-risk subsets of patients with CHF, myocardial infarction within 2 months preceding entry and patients with prior cardiac arrest or arrhythmia were analyzed separately by Cox analysis. The number of vessels diseased and left ventricular wall motion were the two most important variables predictive of survival in each group. Digitalis therapy failed to enter the final model in any subset of patients studied. The expected mortality of our study population classified according to the degree of CHF was similar to the observed mortality whether the patients were on or off digitalis. This study fails to confirm the findings of earlier reports showing a substantial mortality associated with digitalis use in certain high-risk subsets of patients with coronary artery disease. Although we could demonstrate no benefit in terms of survival for patients receiving digitalis in this population study, we conclude that digitalis therapy is not likely to be an independent risk factor contributing significantly to mortality in patients with coronary artery disease.

A of the arteries in the human is a pathological process with serious consequences. It results in loss of elasticity of vessel walls, in focal development of plaques, and in irregular narrowing of the arterial lumen. The resultant impairment of blood flow may lead to heart attack, stroke, or gangrene of the limbs. The currently acceptable clinical method for providing the best quantitative measures of the extent of atherosclerotic lesions is angiography, which is time-consuming and expensive and which also carries a small but significant risk to the patient. Subjective interpretations of the angiogram and projection errors result in variability in sensitivity and specificity. Image-processing techniques may overcome some of the problems, but inconsistencies remain. Furthermore, the invasiveness of the procedure generally precludes repeat angiograms at frequent intervals.

The complications reported in the first 1500 patients enrolled in the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry are analyzed. Data were contributed from 73 centers between September 1977 and April 1981. PTCA was successful in 63% of attempts. Five hundred forty-three in-hospital complications occurred in 314 patients (21%). The most frequent complications were prolonged angina in 121, myocardial infarction (MI) in 72, and coronary occlusion in 70. One hundred thirty-eight patients (9.2%) had major complications (MI, emergency

The prevalence of coronary artery stenoses 2 70% or left main stenosis > 50% was evaluated in 20,391 patients who underwent angiography in the Coronary Artery Surgery Study from 1975-1979. After the patients with unstable angina or myocardial infarction were excluded, the disease prevalence in the 8157 patients with definite angina, probable angina, and nonspecific chest pain was 93%, 66% and 14% in men and 72%, 36% and 6% in women (p < 0.001). The age and sex of the patients and character of chest pain were important determinants of disease prevalence and severity. Left main or three-vessel coronary disease occurred in more than 50% of middle-aged

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.

HomeCirculationVol. 99, No. 14Women Versus Men Regarding Outcome of CABG or PTCA Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBWomen Versus Men Regarding Outcome of CABG or PTCA Tsung O. Cheng Tsung O. ChengTsung O. Cheng Professor of Medicine The George Washington University, Washington, DC Originally published13 Apr 1999https://doi.org/10.1161/circ.99.14.1922/eCirculation. 1999;99:1922e–1926To the Editor:It is very gratifying to read from the report from the Bypass Angioplasty Revascularization Investigation (BARI)1 that women who undergo coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) fare as well as men. However, this conclusion seems to be at odds with another report2 published at about the same time and based on a much larger number of patients (344 913 compared with 1829 in BARI). The registry from the Society of Thoracic Surgeons2 reported that women clearly have a higher mortality rate within 30 days of a procedure (4.52% in women versus 2.61% in men; P<0.001). The report, after adjusting the data for more than 50 potential risk factors, still found a statistically significant higher death rate for women.3Conventional wisdom tells us that women are at higher risk than men for CABG and PTCA because women have smaller, more technically challenging coronary arteries; there is less frequent use of internal mammary artery grafting in women; women develop symptoms from coronary artery disease at an older age than men owing to protection from estrogen; and women are more likely as a result to have such comorbid conditions as diabetes mellitus and renal disease that increase the operative risks.The issue of whether men do better than women or women do equally well as men in outcomes with CABG and PTCA remains debatable. But the most important message from BARI1 is that it is reassuring that women do not seem to do worse and therefore gender of the patient should not influence a physician's decision to recommend medical versus surgical treatment of coronary artery disease. References 1 Jacobs AK, Kelsey SF, Brooks MM, Faxon DP, Chaitman BR, Bittner V, Mock MB, Weiner BH, Dean L, Winston C, Drew L, Sopko G. Better outcome for women compared with men undergoing coronary revascularization: a report from the Bypass Angioplasty Revascularization Investigation (BARI). Circulation.1998; 98:1279–1285.CrossrefMedlineGoogle Scholar2 Edwards FH, Carey JS, Grover FL, Bero JW, Hartz RS. Impact of gender on coronary bypass operative mortality. Ann Thorac Surg.1998; 66:125–131.CrossrefMedlineGoogle Scholar3 Winslow R. Gender effect in heart surgery is disputed. Wall Street Journal. September 29, 1998:B12.Google ScholarcirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinsResponseJacobs Alice K., MD, Kelsey Sheryl F., PhD, Brooks Maria Mori, PhD, Faxon David P., MD, Chaitman Bernard R., MD, Bittner Vera, MD, Dean Larry, MD, Mock Michael B., MD, Weiner Bonnie H., MD, Winston Carla, MA, Drew Laura, RN, and Sopko George, MD, MPH13041999We appreciate the comments of Dr Cheng, who notes that the finding of a similar outcome in women and men undergoing CABG within the Bypass Angioplasty Revascularization Investigation (BARI)R1 is not corroborated in a large registry of patients in the Society of Thoracic Surgeons National Cardiac Surgery Database.R2As stated in the Discussion, interpretation of our results in BARI should take into account that the data are from a randomized clinical trial with specific inclusion and exclusion criteria, and hence, the BARI population is not representative of all patients undergoing coronary revascularization. However, when we examined BARI screening data, we found that women were not disproportionately excluded from the trial population. In addition, data from an ancillary BARI study that conducted a survey of all hospitals in the United States performing CABG and coronary angioplasty during the same time period indicated that the proportion of women undergoing revascularization procedures at BARI sites was similar to the proportion of women undergoing revascularization at a random sample of hospitals around the country (between 26% and 27% of patients and similar to the 26.7% of women in the trial).R3 Thus, there does not appear to be a sex bias for selection into BARI. Similar to other observational studies, women in BARI were older and had a higher risk profile and more comorbid disease than men. However, the detailed inclusion criteria, most notably that the coronary anatomy had to be amenable to both CABG and coronary angioplasty, suggest that the BARI population represents a subset of all patients treated with CABG.We agree with Dr Cheng that it is unclear whether women do as well as men when undergoing CABG and coronary angioplasty. However, what is important is that the outcome of women undergoing coronary revascularization appears to be improving, as suggested in 2 recent preliminary reports that noted a similar adjusted mortality in women and men undergoing percutaneous coronary intervention within the NHLBI Dynamic RegistryR4 and the Northern New England Cardiovascular Disease Study Group registry.R5 These data should be disseminated to clinicians to ensure optimal management of women in need of a coronary revascularization procedure. 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BACKGROUNDNumerous 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 RESULTSWe 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.CONCLUSIONSAlthough 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.

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 m. 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.

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)

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), history of myocardial infarction (p = 0.01), 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 β-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.

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.

During the 44 years since Congress established the National Heart Institute, dedicated scientists in a broad array of both biologic and physical sciences have provided a veritable explosion of knowledge about the mechanisms of cardiovascular disease. These major advances have been translated to effective and sophisticated methods of cardiovascular diagnosis, therapy, and prevention. Consequently, many lives have been saved. Since 1975, the estimated years of life lost annually to cancer in the United States have exceeded those lost from heart disease.

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 ? 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.

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.