This study compared the 10-year follow-up of percutaneous coronary intervention (PCI), coronary artery surgery (CABG), and medical treatment (MT) in patients with multivessel coronary artery disease, stable angina, and preserved ventricular function.
The primary end points were overall mortality, Q-wave myocardial infarction, or refractory angina that required revascularization. All data were analyzed according to the intention-to-treat principle. At a single institution, 611 patients were randomly assigned to CABG (n=203), PCI (n=205), or MT (n=203). The 10-year survival rates were 74.9% with CABG, 75.1% with PCI, and 69% with MT (P=0.089). The 10-year rates of myocardial infarction were 10.3% with CABG, 13.3% with PCI, and 20.7% with MT (P<0.010). The 10-year rates of additional revascularizations were 7.4% with CABG, 41.9% with PCI, and 39.4% with MT (P<0.001). Relative to the composite end point, Cox regression analysis showed a higher incidence of primary events in MT than in CABG (hazard ratio 2.35, 95% confidence interval 1.78 to 3.11) and in PCI than in CABG (hazard ratio 1.85, 95% confidence interval 1.39 to 2.47). Furthermore, 10-year rates of freedom from angina were 64% with CABG, 59% with PCI, and 43% with MT (P<0.001).
Compared with CABG, MT was associated with a significantly higher incidence of subsequent myocardial infarction, a higher rate of additional revascularization, a higher incidence of cardiac death, and consequently a 2.29-fold increased risk of combined events. PCI was associated with an increased need for further revascularization, a higher incidence of myocardial infarction, and a 1.46-fold increased risk of combined events compared with CABG. Additionally, CABG was better than MT at eliminating anginal symptoms. Clinical Trial Registration Information- URL: http://www.controlled-trials.com. Registration number: ISRCTN66068876.
"The MASS II study design has been previously described . We performed a post hoc analysis specifically of 188 (30.8%) women in the prospective MASS II study with 10 years of follow-up (mean ± standard deviation: 6.8 ± 3.7 years), which randomized a total of 611 patients with multivessel chronic stable CAD to optimal MT, PCI, or CABG after the agreement, respectively, of the clinician, the interventionist and the cardiac surgeon. "
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES Coronary artery disease is the leading cause of death in women. The proposed treatments for women are similar to those for
men. However, in women with multivessel stable coronary artery disease and normal left ventricular function, the best treatment
Interactive Cardiovascular and Thoracic Surgery 09/2014; 19(6). DOI:10.1093/icvts/ivu288 · 1.16 Impact Factor
"It is important to note that in the present investigation, the survival curves started to diverge after 5 years, which is pertinent because 5 years was the length of the follow-up period in previous trials exploring the role of Lp(a) levels and apo(a) phenotype in prognosis after CABG. The rate of survival free of major coronary events observed in the present study was very similar to that registered in the CABG arm of the randomized Medicine, Angioplasty, or Surgery Study (MASS II) . In a recent Japanese study, the authors enrolled 1074 consecutive patients who underwent CABG and followed them for 10 years; increased levels of non-HDL cholesterol were a significant and independent (of other lipid parameters) predictor of cardiac death . "
[Show abstract][Hide abstract] ABSTRACT: Objective
To evaluate the relationships of lipoprotein(a) (Lp(a)) concentration and apolipoprotein(a) (apo(a)) phenotype to major adverse cardiovascular events after coronary artery bypass grafting (CABG) in long-term follow-up.
This single-center study included 356 patients with stable coronary heart disease (CHD) who underwent successful CABG. At baseline, we assessed the patient’s risk factor profile for atherosclerosis, Lp(a) concentration and apo(a) phenotype. The primary endpoint was the composite of cardiovascular death and non-fatal myocardial infarction (MI). The secondary endpoint also included hospitalization for recurrent or unstable angina and repeat revascularization.
Over a mean of 8.5±3.5 years (range 0.9-15.0 years), the primary and secondary endpoints were registered in 46 (13%) and 107 (30%) patients, respectively. Patients with Lp(a) ≥30 mg/dL were at significantly greater risk for the primary endpoint (hazard ratio (HR) 2.98, 95% confidence interval (CI) 1.76-5.03, p<0.001) and secondary endpoint (HR 3.47, 95% CI 2.48-4.85, p<0.001) than patients with Lp(a) values <30 mg/dL. The low molecular-weight apo(a) phenotype was also associated with higher risk of both primary and secondary endpoints (3.57 (1.87-6.82) and 3.05 (2.00-4.62), respectively; p<0.001 for both), regardless of conventional risk factors and statins use.
In stable CHD patients Lp(a) concentration and low molecular-weight apo(a) phenotype are independently associated with three-fold increase in risk of major adverse cardiovascular events within 15 years after CABG. Lp(a) levels may provide an additional information for postoperative cardiovascular risk assessment.
"In MASS II, a 10-year comparison of PCI, CAB, and MT which is underpowered but demonstrates equivalence in survival with each treatment modality, CAB and PCI were associated with a lower incidence of primary events than MT . In stable patients this study supports an initial strategy of MT with careful follow-up to determine a later need for intervention . "
[Show abstract][Hide abstract] ABSTRACT: Strategic planning is integral to any operation but complexity varies immensely and therefore the effort necessary to create the optimal plan. The previous three reports have discussed individual conduits and herein is an attempt to present approaches to common situations which the author favors. Although much has been learned over 45 years about use and subsequent behavior of venous and arterial grafts we continue to learn and, as a result, evolve new strategies or modify those now popular. Thus the reader must recognize that in spite of trying to be balanced and inclusive all surgeons have personal opinions and also prejudices which influence the approach taken and which may not be the optimal one for others or for the patient.
Korean Journal of Thoracic and Cardiovascular Surgery 10/2013; 46(5):319-327. DOI:10.5090/kjtcs.2013.46.5.319
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