Circulation, Vol 86, 121-130, Copyright © 1992 by American Heart Association
BACKGROUND. The 18-year effect of bypass surgery compared with medical
therapy on survival, incidence of myocardial infarction, and relief of
angina was evaluated in 686 randomized patients with stable angina in the
Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery.
METHODS AND RESULTS. The primary treatment comparisons were made according
to intent to treat; 44% of the entire medical cohort had bypass surgery
during a median follow-up of 16.8 years. Overall 18-year survival rates
were 33% for medicine compared with 30% for surgery (p = 0.60). Survival
rates for high-risk patients without left main disease, which had shown a
significant advantage for surgical therapy up to 11 years, were 23%
medicine versus 24% surgery for patients with three- vessel disease and
impaired left ventricular function (p = 0.49) and 22% versus 25% for those
with multiple clinical risk factors (p = 0.12). For patients with
two-vessel disease, who had significantly better survival with medical
therapy at 11 years, rates were similar at 18 years in the two treatment
groups (34% medicine versus 30% surgery, p = 0.09). Cumulative 18-year
myocardial infarction rates (fatal plus nonfatal) were 41% in medical and
49% in surgical patients (13% perioperative infarction rate), p = 0.15.
Nonfatal infarction rates were lower with medical than with surgical
therapy (32% versus 44%, p = 0.015), but fatal infarction rates were
similar (14% medicine versus 13% surgery, p = 0.62). The combined rate of
myocardial infarction or death was also lower with medical therapy (75%
versus 82%, p = 0.016). In contrast, surgery reduced mortality after
myocardial infarction by 35% at 10 years (p less than 0.001) but only by
13% at 18 years (p = 0.09). The percent of medical and surgical patients
who were angina- free was 3% versus 22% (p less than 0.001) at 1 year and
4% versus 12% (p less than 0.001) at 5 years compared with rates of 6%
versus 5% (p greater than 0.50) at 10 years and 3% versus 4% (p greater
than 0.50) at 15 years. CONCLUSIONS. The benefits of coronary artery bypass
surgery on survival, symptoms, and postinfarction mortality were transient
and lasted fewer than 11 years. The benefits began to diminish after 5
years, when graft closure accelerated. Surgery was effective in reducing
mortality only for patients with a poor natural history. Low-risk patients,
who had a good prognosis with medical therapy, derived no survival benefit
with surgical therapy at any time during the follow-up period. Regardless
of risk, surgery also did not reduce the incidence of myocardial infarction
or the combined incidence of infarction or death.
ARTICLES
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
Cooperative Studies Program, VA Medical Center, West Haven, Conn 06516.
This article has been cited by other articles:
 |
|
 |
|
  A. Cassar, D. R. Holmes Jr, C. S. Rihal, and B. J. Gersh Chronic Coronary Artery Disease: Diagnosis and Management Mayo Clin. Proc., December 1, 2009; 84(12): 1130 - 1146. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. K. Song, B. S. Diggs, M. S. Slater, S. W. Guyton, R. M. Ungerleider, and K. F. Welke Improved quality and cost-effectiveness of coronary artery bypass grafting in the United States from 1988 to 2005. J. Thorac. Cardiovasc. Surg., January 1, 2009; 137(1): 65 - 69. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J. Synnergren, R. Ekroth, A. Oden, H. Rexius, and L. Wiklund Incomplete revascularization reduces survival benefit of coronary artery bypass grafting: Role of off-pump surgery J. Thorac. Cardiovasc. Surg., July 1, 2008; 136(1): 29 - 36. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. P. Brown, A. D. Kugelmass, D. J. Cohen, M. R. Reynolds, S. D. Culler, A. D. Dee, and A. W. Simon The Frequency and Cost of Complications Associated With Coronary Artery Bypass Grafting Surgery: Results from the United States Medicare Program Ann. Thorac. Surg., June 1, 2008; 85(6): 1980 - 1986. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. L. Brown, T. M. Sundt III, and B. J. Gersh Indications for Revascularization Card. Surg. Adult, January 1, 2008; 3(2008): 551 - 572. [Full Text]
|
|
|
|
 |
|
 V. J. Dzau, E. M. Antman, H. R. Black, D. L. Hayes, J. E. Manson, J. Plutzky, J. J. Popma, and W. Stevenson The Cardiovascular Disease Continuum Validated: Clinical Evidence of Improved Patient Outcomes: Part I: Pathophysiology and Clinical Trial Evidence (Risk Factors Through Stable Coronary Artery Disease) Circulation, December 19, 2006; 114(25): 2850 - 2870. [Full Text] [PDF]
|
|
|
|
|
|
G. Gao, Y. Wu, G. L. Grunkemeier, A. P. Furnary, and A. Starr Long-term survival of patients after coronary artery bypass graft surgery: comparison of the pre-stent and post-stent eras. Ann. Thorac. Surg., September 1, 2006; 82(3): 806 - 810. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Yamaguchi, H. Adachi, K. Kawahito, S. Murata, and T. Ino Left Ventricular Reconstruction Benefits Patients With Dilated Ischemic Cardiomyopathy Ann. Thorac. Surg., February 1, 2005; 79(2): 456 - 461. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Landesberg, M. Mosseri, Y. G. Wolf, M. Bocher, A. Basevitch, E. Rudis, U. Izhar, H. Anner, C. Weissman, and Y. Berlatzky Preoperative Thallium Scanning, Selective Coronary Revascularization, and Long-Term Survival After Major Vascular Surgery Circulation, July 15, 2003; 108(2): 177 - 183. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. W. Lytle The role of coronary revascularization in the treatment of ischemic cardiomyopathy Ann. Thorac. Surg., June 1, 2003; 75(90060): S2 - 5. [Full Text] [PDF]
|
|
|
|
 |
|
 A Jain, V Wadehra, and A D Timmis Management of stable angina Postgrad. Med. J., June 1, 2003; 79(932): 332 - 336. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Brueck, W. Kramer, P. R. Vogt, W. G. Daniel, H. Tillmanns, and J. Ludwig Patency rates of three arterial grafting patterns to the left anterior descending and diagonal coronary arteries in symptomatic patients Ann. Thorac. Surg., April 1, 2003; 75(4): 1161 - 1164. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. M. Sundt III, B. J. Gersh, and H. C. Smith Indications for Coronary Revascularization Card. Surg. Adult, January 1, 2003; 2(2003): 541 - 559. [Full Text]
|
|
|
|
 |
|
 R. M. Poses, J. I. Krueger, S. Sloman, and A. S. Elstein Physicians' Judgments of Survival After Medical Management and Mortality Risk Reduction Due to Revascularization Procedures for Patients With Coronary Artery Disease* Chest, July 1, 2002; 122(1): 122 - 133. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. D. Fihn, S. V. Williams, J. Daley, and R. J. Gibbons Guidelines for the Management of Patients with Chronic Stable Angina: Treatment Ann Intern Med, October 16, 2001; 135(8_Part_1): 616 - 632. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C.V Patil, E Nikolsky, M Boulos, E Grenadier, and R Beyar Multivessel coronary artery disease: current revascularization strategies Eur. Heart J., July 2, 2001; 22(14): 1183 - 1197. [PDF]
|
|
|
|
 |
|
 S. C. Smith Jr, J. T. Dove, A. K. Jacobs, J. Ward Kennedy, D. Kereiakes, M. J. Kern, R. E. Kuntz, J. J. Popma, H. V. Schaff, D. O. Williams, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines): A report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2239 - 2239. [Full Text] [PDF]
|
|
|
|
 |
|
 D. Katz, D. Payne, and S. Pauker Early Surgery versus Conservative Management of Dissecting Aneurysms of the Descending Thoracic Aorta Med Decis Making, October 1, 2000; 20(4): 377 - 390. [Abstract] [PDF]
|
|
|
|
|
|
V. Mathew, D. E. Grill, C. G. Scott, J. A. Grantham, H. H. Ting, K. N. Garratt, and D. R. Holmes Jr. The influence of abciximab use on clinical outcome after aortocoronary vein graft interventions J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1163 - 1169. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Gibbons, K. Chatterjee, J. Daley, J. S. Douglas, S. D. Fihn, J. M. Gardin, M. A. Grunwald, D. Levy, B. W. Lytle, R. A. O'Rourke, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina) J. Am. Coll. Cardiol., June 1, 1999; 33(7): 2092 - 2197. [Full Text] [PDF]
|
|
|
|
 |
|
 M. S. Gotsman and D. Admon Paradigm Shifts in Coronary Artery Disease: The Old New Initiatives Arch Intern Med, May 11, 1998; 158(9): 949 - 953. [Full Text] [PDF]
|
|
|
|
 |
|
 H. Ueno, J.-J. Li, S. Masuda, Z. Qi, H. Yamamoto, and A. Takeshita Adenovirus-Mediated Expression of the Secreted Form of Basic Fibroblast Growth Factor (FGF-2) Induces Cellular Proliferation and Angiogenesis In Vivo Arterioscler Thromb Vasc Biol, November 1, 1997; 17(11): 2453 - 2460. [Abstract] [Full Text]
|
|
|
|
 |
|
 G. J. Friedrich, J. Bonatti, and O. E. Dapunt Preliminary Experience with Minimally Invasive Coronary-Artery Bypass Surgery Combined with Coronary Angioplasty N. Engl. J. Med., May 15, 1997; 336(20): 1454 - 1455. [Full Text]
|
|
|
|
|
|
R. C. Schlant Coronary Angioplasty in Patients With Stable Angina Pectoris and One-Vessel Disease Circulation, October 1, 1995; 92(7): 1676 - 1677. [Full Text]
|
|