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Coronary bypass surgery in chronic stable angina
B J Gersh1, R M Califf, F D Loop
1Mayo Clinic, Rochester, Minnesota, 55905.
Insights
Coronary artery bypass surgery improves survival for high-risk patients with chronic stable angina. However, outcomes may be impacted by expanding surgery to elderly and high-risk individuals.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Outcomes Research
Background:
- Coronary artery bypass surgery (CABS) has shown improved outcomes over 20 years.
- The procedure is increasingly performed on elderly and high-risk patients.
- This shift may impact future survival trends.
Purpose of the Study:
- To analyze predictors of operative mortality and late death after CABS.
- To evaluate the survival benefit of CABS versus medical therapy in different risk groups.
Main Methods:
- Review of randomized trials and registry studies.
- Analysis of clinical, functional, and anatomic characteristics as predictors.
- Comparison of CABS outcomes with medical therapy.
Main Results:
- Left ventricular function, age, and comorbidities are key predictors of operative mortality.
- Left ventricular dysfunction is the strongest predictor of late death.
- CABS prolongs survival in high-risk patients compared to medical therapy alone.
Conclusions:
- CABS remains beneficial for high-risk patients with chronic stable angina.
- Medical therapy is initially recommended for low-risk patients.
- Risk stratification is crucial for guiding treatment decisions in coronary artery disease.
Abstract:
Over the last 20 years, operative mortality has decreased and late survival has improved for patients with chronic stable angina who have coronary artery bypass surgery. However, this favorable trend may not continue because the operation is now extended to elderly and high-risk patients. The most powerful predictors of operative mortality include indexes of left ventricular function, age, and the number of associated medical conditions. Female gender, severity of angina, and extent of coronary artery disease appear to be predictors of operative mortality in some series but not in all. Indexes of left ventricular dysfunction remain the most powerful predictors of late death, but the extent of coronary disease, older age, and presence of associated diseases (including noncardiac vascular disease) remain important determinants. Analyses of the randomized trials and registry studies reveal a consistent trend: in patients at high risk on the basis of clinical, functional, and anatomic characteristics, coronary artery bypass surgery prolongs survival in comparison with medical therapy alone. In patients determined to be at low risk, medical therapy is initially recommended with the realization that revascularization may be necessary subsequently if symptoms worsen or the severity of ischemia increases.