Conclusions As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy. (ClinicalTrials.gov number,
http://content.nejm.org/cgi/content/abstract/297/12/621
Treatment of chronic stable angina. NEJM Volume 297:621-627 September 22, 1977 Number 12. A preliminary report of survival data of the randomized Veterans Administration cooperative study ML Murphy, HN Hultgren, K Detre, J Thomsen, and T Takaro
We evaluated the effect of saphenous-vein-bypass grafting on survival in patients with chronic stable angina by comparing medical and surgical treatment in a large-scale, prospective randomized study. Excluding patients with left-main-coronary-artery disease who have already been reported, a total of 596 patients were entered into this study; when randomized into a medical group (310 patients) and a surgical group (286 patients), entry clinical and angiographic base lines were comparable. Operative mortality at 30 days was 5.6 per cent. At an average of one year after operation, 69 per cent of all grafts were patent, and 88 per cent of the surgical patients had atleast one patent graft. There was no statistically significant difference in survival, at a minimal follow-up interval of 21 months, between patients treated medically and those treated with saphenous-vein-bypass grafting. At 36 months, 87 per cent of the medical group and 88 per cent of the surgical group were alive.
http://www.ncbi.nlm.nih.gov/pubmed/6608052?dopt=Abstract
NEJM 1984 Mar 22;310(12):750-8
Myocardial infarction and mortality in the coronary artery surgery study (CASS) randomized trial.
The long-term benefit of coronary bypass surgery in terms of longevity and prevention of major ischemic events in patients who have mild angina is not well defined. The randomized Coronary Artery Surgery Study (CASS) was designed to evaluate this issue; it consists of 780 patients who were considered operable and who had mild stable angina pectoris or who were free of angina after infarction. As a result of the randomization process there were no significant differences in base-line variables between patients randomly assigned to medical and to surgical therapy. The likelihood of death in the five-year period after randomization was only 8 per cent in the medical cohort, as compared with 5 per cent in the surgical cohort (not significant). The likelihood of nonfatal Q-wave myocardial infarction was 11 and 14 per cent, respectively (not significant). The five-year probability of remaining alive and free of infarction was 82 per cent in the patients assigned to medical therapy and 83 per cent in the patients assigned to surgery (not significant). There were no statistically significant differences in the survival rate or in the myocardial-infarction rate between subgroups of patients randomly assigned to medical and to surgical therapy when they were analyzed according to initial group assignment, number of diseased vessels, or ejection fraction. Therefore, as compared with medical therapy, coronary bypass surgery appears neither to prolong life nor to prevent myocardial infarction in patients who have mild angina or who are asymptomatic after infarction in the five-year period after coronary angiography.
http://www.ncbi.nlm.nih.gov/pubmed/6128492?dopt=Abstract
Lancet 1982 Nov 27;2(8309):1173-80. Long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. European Coronary Surgery Study Group.
This report presents the final results (follow-up 5--8 years) of a prospective study in 768 men aged under 65 with mild to moderate angina, 50% or greater stenosis in at least two major coronary arteries, and good left ventricular function. 395 were randomised to coronary artery bypass surgery, 373 to no treatment; 1 patient in the surgery group was lost to follow-up. These original groups were compared, whatever subsequently happened to the patients. Survival was improved significantly by surgery in the total population, in patients with three-vessel disease, and in patients with stenosis in the proximal third of the left anterior descending artery constituting a component of either two or three vessel disease, and non-significantly in patients with left main coronary disease. An abnormal electrocardiogram at rest, ST-segment depression greater than or equal to 1.5 mm during exercise, peripheral arterial disease, and increasing age independently point to a better chance of survival with surgery. In the absence of these prognostic variables in patients with either two or three vessel disease the outlook is so good that early surgery is unlikely to increase the prospect of survival. In terms of anginal attacks, use of beta-adrenergic blockers and nitrates, and exercise performance the surgical group did significantly better than the medical group throughout the 5 years of follow-up, but the difference between the two treatments tended to decrease.
http://www.heartprotect.com/comparison-studies.shtml
COMPARISON OF INVASIVE VS. NONINVASIVE THERAPIES AND RELATED STUDIES
http://content.nejm.org/cgi/content/abstract/297/12/621
Treatment of chronic stable angina. A preliminary report of survival data of the randomized Veterans Administration cooperative study ML Murphy, HN Hultgren, K Detre, J Thomsen, and T Takaro Abstract
We evaluated the effect of saphenous-vein-bypass grafting on survival in patients with chronic stable angina by comparing medical and surgical treatment in a large-scale, prospective randomized study. Excluding patients with left-main-coronary-artery disease who have already been reported, a total of 596 patients were entered into this study; when randomized into a medical group (310 patients) and a surgical group (286 patients), entry clinical and angiographic base lines were comparable. Operative mortality at 30 days was 5.6 per cent. At an average of one year after operation, 69 per cent of all grafts were patent, and 88 per cent of the surgical patients had atleast one patent graft. There was no statistically significant difference in survival, at a minimal follow-up interval of 21 months, between patients treated medically and those treated with saphenous-vein-bypass grafting. At 36 months, 87 per cent of the medical group and 88 per cent of the surgical group were alive.
Volume 297:621-627 September 22, 1977 Number 12
http://www.heartprotect.com/comparison-studies.shtml
COMPARISON OF INVASIVE VS. NONINVASIVE THERAPIES AND RELATED STUDIES
(1) http://content.nejm.org/cgi/content/abstract/338/25/1785
Non-Q-wave Myocardial Infarction Following Thrombolytic Therapy: A Comparison of Outcomes in Patients Randomized to Invasive or Conservative Post-Infarct Assessment Strategies in the Veterans Affairs Non-Q-Wave Infarction Strategies In-Hospital (VANQWISH) Trial.. Wexler,LF, Blaustein, AS, Philip W. Lavori, PW, et al. Journal of the American College of Cardiology. ; 2001; 37: 19-25. (Circulation. 1998;97:444-450.) Overall event rates (death or recurrent nonfatal heart attack ) were considerably more with invasive strategies than in patients with conservative treatment following thrombolytic therapy. Mortality rate in patients managed conservatively is low (3.5%), and routine invasive management was associated with an increased risk of death.
(2) http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=27425 BMJ. 2000 July 8; 321(7253): 73–77.
Percutaneous Transluminal Angioplasty Versus Medical Treatment For Non-Acute Coronary Heart Disease. The procedure may lead to an increase in coronary bypass grafting compared with medical treatment and is unlikely to reduce non-fatal myocardial infarction, death, or repeated angioplasty.
(3) http://www.ncbi.nlm.nih.gov/pubmed/10892758
An Invasive Strategy Reduced Death, Myocardial Infarction and Readmissions in Unstable Coronary Artery Disease.
Wallentin L, Lagerqvist B, Husted E, et al., for the FRISC II Investigators. Lancet. 2000; 356: 9-16.
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