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Comparison of medicine alone, coronary angioplasty, and left internal mammary artery–coronary artery bypass for one-vessel proximal left anterior descending coronary artery disease

      Abstract

      Despite the deleterious and sometimes catastrophic consequences of proximal left anterior descending (LAD) artery occlusion, there is a paucity of data to guide the treatment of patients with such disease. Our aim was to describe outcomes with medical therapy, angioplasty, or left internal mammary artery (LIMA) bypass grafting in patients with 1-vessel, proximal LAD disease. We retrospectively analyzed prospectively collected data from 1,188 patients first presenting only with proximal LAD disease at 1 center over 9 years. We assessed the rates of death, acute myocardial infarction, and repeat intervention by initial treatment over a median 5.7 years of follow-up. Patients undergoing angioplasty or LIMA bypass were more often men and had progressive or unstable angina; those receiving medical therapy had a lower median ejection fraction. Both revascularization procedures offered slightly better adjusted survival versus medicine (hazard ratio for angioplasty, 0.82; 95% confidence interval, 0.60 to 1.11; hazard ratio for bypass, 0.74; 95% confidence interval, 0.44 to 1.23). Bypass, but not angioplasty, was associated with significantly fewer composite end point events (death, infarction, or reintervention, p <0.0001), and angioplasty was associated with a higher composite event rate than bypass or medical therapy (p <0.0001 and p = 0.0003, respectively). The initial advantages of bypass and medicine over angioplasty diminished over time; angioplasty became more advantageous than medicine after 1 year (p = 0.05) and not significantly different from bypass. Treatment of 1-vessel, proximal LAD disease with medicine, angioplasty, or LIMA bypass resulted in comparable adjusted survival. However, LIMA bypass alone reduced the long-term incidence of infarctions and repeat procedures.
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      References

        • CASS Principal Investigators and their associates
        Coronary artery surgery study (CASS).
        Circulation. 1983; 68: 939-950
        • Varnauskas E
        Twelve-year follow-up of survival in the randomized European Coronary Surgery Study.
        N Engl J Med. 1988; 319: 332-337
        • Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group
        Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina.
        N Engl J Med. 1984; 311: 1333-1339
        • Yusuf S
        • Zucker D
        • Peduzzi P
        • Fisher L.D
        • Takaro T
        • Kennedy J.W
        • Davis K
        • Killip T
        • Passamani E
        • Norris R
        • Morris C
        • Mathur V
        • Varnauskas E
        • Chalmers T.C
        Effect of coronary artery bypass graft surgery on survival.
        Lancet. 1994; 344: 563-570
        • Jones R.H
        • Kesler K
        • Phillips III, H.R
        • Mark D.B
        • Smith P.K
        • Nelson C.L
        • Newman M.F
        • Reves J.G
        • Anderson R.W
        • Califf R.M
        Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease.
        J Thorac Cardiovasc Surg. 1996; 111: 1013-1025
        • Kramer J.R
        • Proudfit W.L
        • Loop F.D
        • Goormastic M
        • Zimmerman K
        • Simpfendorfer C
        • Horner G
        Late follow-up of 781 patients undergoing percutaneous transluminal coronary angioplasty or coronary artery bypass grafting for an isolated obstruction in the left anterior descending coronary artery.
        Am Heart J. 1989; 118: 1144-1153
        • Cameron J
        • Mahanonda N
        • Aroney C
        • Hayes J
        • McEniery P
        • Gardner M
        • Bett N
        Outcome five years after percutaneous transluminal coronary angioplasty or coronary artery bypass grafting for significant narrowing limited to the left anterior descending coronary artery.
        Am J Cardiol. 1994; 74: 544-549
        • Goy J.J
        • Eeckhout E
        • Burnand B
        • Vogt P
        • Stauffer J.-C
        • Hurni M
        • Stumpe F
        • Ruchat P
        • Sadeghi H
        • Kappenberger L
        Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis.
        Lancet. 1994; 343: 1449-1453
        • Hueb W.A
        • Bellotti G
        • de Oliveira S.A
        • Arie S
        • de Albuquerque C.P
        • Jatene A.D
        • Pileggi F
        The Medicine, Angioplasty or Surgery Study (MASS).
        J Am Coll Cardiol. 1995; 26: 1600-1605
        • Rosati R.A
        • McNeer J.F
        • Starmer C.F
        • Mittler B.S
        • Morris J.J
        • Wallace A.G
        A new information system for medical practice.
        Arch Intern Med. 1975; 135: 1017-1024
        • Buller C
        • Mark D.B
        • Phillips III, H.R
        • Stack R.S
        Cardiac catheterization and percutaneous coronary angioplasty.
        in: Sabiston Jr, D.C The Davis-Christopher Textbook of Surgery. WB Saunders, Philadelphia1991: 1826-1843
        • Rankin J.S
        • Sabiston Jr, D.C
        The coronary circulation.
        in: Sabiston Jr, D.C Textbook of Surgery. WB Saunders, Philadelphia1991: 1957-1972
        • Mark D.B
        • Nelson C.L
        • Califf R.M
        • Harrell Jr, F.E
        • Lee K.L
        • Jones R.H
        • Fortin D.F
        • Stack R.S
        • Glower D.D
        • Smith L.R
        • DeLong E.R
        • Smith P.K
        • Reves J.G
        • Jollis J.G
        • Tcheng J.E
        • Muhlbaier L.H
        • Lowe J.E
        • Phillips H.R
        • Pryor D.B
        Continuing evolution of therapy for coronary artery disease.
        Circulation. 1994; 89: 2015-2025
        • Charlson M.E
        • Pompei P
        • Alex K.L
        • MacKenzie C.R
        A new method of classifying prognostic comorbidity in longitudinal studies.
        J Chronic Dis. 1987; 40: 373-383
        • Kaplan E.L
        • Meier P
        Nonparametric estimation from incomplete observations.
        J Am Stat Assoc. 1958; 53: 457-481
        • Serruys P.W
        • de Jaegere P
        • Kiemeneij F
        • Macaya C
        • Rutsch W
        • Heyndrickx G
        • Emanuelsson H
        • Marco J
        • Legrand V
        • Materne P
        • Belardi J
        • Sigwart U
        • Colombo A
        • Goy J.J
        • Van den Heuvel P
        • Delcan J
        • Morel M
        • BENESTENT Study Group
        A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease.
        N Engl J Med. 1994; 331: 489-495
        • Versaci F
        • Gaspardone A
        • Tomai F
        • Crea F
        • Chiariello L
        • Gioffre P.A
        A comparison of coronary-artery stenting with angioplasty for isolated stenosis of the proximal left anterior descending coronary artery.
        N Engl J Med. 1997; 336: 817-822
        • Kong D.F
        • Califf R.M
        • Miller D.P
        • Moliterno D.J
        • White H.D
        • Harrington R.A
        • Tcheng J.E
        • Lincoff A.M
        • Hasselblad V
        • Topol E.J
        Clinical outcomes of therapeutic agents that block the platelet glycoprotein IIb/IIIa integrin in ischemic heart disease.
        Circulation. 1998; 98: 2829-2835