Chronic stable angina coronary artery bypass grafting versus medical therapy
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Chronic stable angina Microchapters | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Alternative Therapies for Refractory Angina | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.
Overview
In selected patients with stable angina, revascularization with CABG has shown to provide better symptomatic benefit and improved survival rates in comparison to medical therapy.[1]
Symptomatic Benefit
- One of the earliest study that compared the benefit of CABG versus medical therapy in the management of stable angina was the Coronary Artery Surgery Study (1990). This study demonstrated that more patients were angina-free after CABG as observed during one year (66% in the CABG group versus 30% in the medically treated group) and five-year follow-up (63% versus 38%). However, at ten-year follow-up these advantages were much less apparent and almost similar in both the groups (47% versus 42%) secondary to the recurrence of symptoms in the CABG group and also a large portion of medically treated patients underwent CABG at a later date, rendering them asymptomatic.[2]
- Limitations of long-term benefits with CABG include the rate the development of saphenous vein graft disease, progression of atherosclerosis in other coronary vessels and presence of severe LV dysfunction.
- In the CASS registry, 6-8% patients per year underwent repeat surgery for recurrent symptoms and the approximate five-year mortality rate with CABG was 1% per year.[2]
- Another study done in the late 1980's demonstrated that immediate post-CABG approximately 77% patients were free from all ischemic events at 5-years and reported improved survival rates in approximately 80% patients as observed at ten-year follow-up. However, 50% had recurrence of angina and only 15% remained angina-free at 15-year follow-up.[3]
Survival Benefits
- Studies done in the early 1970's-1980's demonstrated no significant survival benefit observed with CABG in comparison to medical therapy alone.[4][5][6][7]
- However, CABG has shown to offer significant survival benefits in patients with high-risk CAD. This includes patients with:
- Left main stenosis or left main equivalent disease.
- Severe proximal LAD stenosis. Proximal LAD stenosis with concurrent RCA obstruction has shown to be associated with worst outcomes in comparison to a lesion present in the distal LAD.[8]
- Triple-vessel disease with severe LV dysfunction.[7][9][10][11][12]
- The 2004 ACC/AHA guidelines on CABG,[13] recommended CABG would benefits patients with:
- One- or two-vessel CAD without significant proximal LAD stenosis but with a large area of viable myocardium and high-risk criteria on noninvasive testing.
- Disabling angina despite maximal noninvasive therapy.
- The benefits of CABG on survival and postinfarction mortality tends to be diminished with long-term follow-up even in high-risk patients,[9][14] and considered to be secondary to the progression of coronary artery disease which could be minimized with the current aggressive risk-factor modification.
References
- ↑ Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB et al. (2006) ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 47 (1):e1-121. DOI:10.1016/j.jacc.2005.12.001 PMID: 16386656
- ↑ 2.0 2.1 Rogers WJ, Coggin CJ, Gersh BJ, Fisher LD, Myers WO, Oberman A et al. (1990) Ten-year follow-up of quality of life in patients randomized to receive medical therapy or coronary artery bypass graft surgery. The Coronary Artery Surgery Study (CASS) Circulation 82 (5):1647-58. PMID: 1977531
- ↑ Kirklin JW, Naftel CD, Blackstone EH, Pohost GM (1989) Summary of a consensus concerning death and ischemic events after coronary artery bypass grafting. Circulation 79 (6 Pt 2):I81-91. PMID: 2655982
- ↑ Murphy ML, Hultgren HN, Detre K, Thomsen J, Takaro T (1977) Treatment of chronic stable angina. A preliminary report of survival data of the randomized Veterans Administration cooperative study. N Engl J Med 297 (12):621-7. DOI:10.1056/NEJM197709222971201 PMID: 331107
- ↑ (1984) Myocardial infarction and mortality in the coronary artery surgery study (CASS) randomized trial. N Engl J Med 310 (12):750-8. DOI:10.1056/NEJM198403223101204 PMID: 6608052
- ↑ Kaiser GC (1986) CABG: lessons from the randomized trials. Ann Thorac Surg 42 (1):3-8. PMID: 2425758
- ↑ 7.0 7.1 Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW et al. (1994) Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 344 (8922):563-70. PMID: 7914958
- ↑ Samaha JK, Connor MJ, Tribble R, Kroetz FW, Sullivan JM, Ramanathan KB et al. (1985) Natural history of left anterior descending coronary artery obstruction: significance of location of stenoses in medically treated patients. Clin Cardiol 8 (8):415-22. PMID: 4028534
- ↑ 9.0 9.1 (1984) Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. N Engl J Med 311 (21):1333-9. DOI:10.1056/NEJM198411223112102 PMID: 6333636
- ↑ Myers WO, Schaff HV, Gersh BJ, Fisher LD, Kosinski AS, Mock MB et al. (1989) Improved survival of surgically treated patients with triple vessel coronary artery disease and severe angina pectoris. A report from the Coronary Artery Surgery Study (CASS) registry. J Thorac Cardiovasc Surg 97 (4):487-95. PMID: 2648078
- ↑ Passamani E, Davis KB, Gillespie MJ, Killip T (1985) A randomized trial of coronary artery bypass surgery. Survival of patients with a low ejection fraction. N Engl J Med 312 (26):1665-71. DOI:10.1056/NEJM198506273122603 PMID: 3873614
- ↑ Alderman EL, Bourassa MG, Cohen LS, Davis KB, Kaiser GG, Killip T et al. (1990) Ten-year follow-up of survival and myocardial infarction in the randomized Coronary Artery Surgery Study. Circulation 82 (5):1629-46. PMID: 2225367
- ↑ Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ et al. (2004) ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 110 (9):1168-76. DOI:10.1161/01.CIR.0000138790.14877.7D PMID: 15339866
- ↑ (1992) Eighteen-year follow-up in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery for stable angina. The VA Coronary Artery Bypass Surgery Cooperative Study Group. Circulation 86 (1):121-30. PMID: 1617765