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Chronic total occlusions of coronary arteries--medical versus surgical treatment
H Wiggers1, H E Bøtker, T T Nielsen
1Department of Cardiology, Skejby Hospital, Denmark.
Insights
For patients with chronic total coronary occlusion and mild angina, coronary artery bypass grafting (CABG) may improve outcomes. Surgical treatment showed a trend towards reduced death or myocardial infarction compared to medical management.
Area of Science:
- Cardiology
- Vascular Surgery
Background:
- Coronary artery bypass grafting (CABG) is standard for severe angina with chronic total coronary occlusion.
- Optimal treatment for chronic total coronary occlusion with mild or no angina remains unclear.
Purpose of the Study:
- To compare the long-term prognosis of medically treated versus surgically treated patients with chronic total coronary occlusion and mild or absent angina.
Main Methods:
- Retrospective analysis of coronary angiographies over 5 years.
- Matched cohort study comparing 77 medically treated patients with 77 CABG patients.
- Outcomes included death, acute myocardial infarction (AMI), and need for repeat CABG.
Main Results:
- CABG patients had more severe angina and anti-anginal drug use at baseline.
- Over 5 years, CABG showed lower rates of death or AMI (16% vs. 27%) and death, AMI, or repeat CABG (16% vs. 34%).
- The reduction in death, AMI, or repeat CABG was statistically significant (p=0.03).
Conclusions:
- Patients with chronic total coronary occlusion and mild or absent anginal symptoms may benefit from CABG.
- Surgical intervention appears to offer a better prognosis in this patient group.
Abstract:
Coronary artery bypass grafting (CABG) is an established treatment of patients with angina pectoris and chronic total coronary occlusion of major coronary arteries. However, in patients with mild or absent angina and chronic total coronary occlusion, optimal treatment is unsettled. We compared the prognosis of patients with chronic total coronary occlusion treated medically because of mild or absent angina with a matched group of patients undergoing CABG. In a retrospective design we evaluated all coronary angiographies performed in our department over a 5-year period. We identified 77 patients with chronic total occlusion of major coronary arteries eligible for CABG but treated medically because of mild or absent angina. The medically treated patients were matched on age, sex and ejection fraction with 77 patients with occluded major coronary arteries and angina pectoris who were treated surgically. The main outcome measures were death, acute myocardial infarction (AMI) and CABG. At baseline, CABG patients demonstrated an increased duration and severity of angina pectoris and an increased consumption of anti-anginal drugs. No differences were found with regard to angiographic parameters. The 5-year event rates (medically treated versus CABG) were: death, 14% vs 7% (p = 0.08); death or AMI; 27% vs 16% (p = 0.10); death, AMI or CABG, 34% vs 16% (p = 0.03) (log-rank statistics). In conclusion, our data indicate that patients with chronic total coronary occlusions and mild or absent anginal symptoms may benefit from surgical treatment.