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(Circulation. 2000;102:157.)
© 2000 American Heart Association, Inc.

Clinical Investigation and Reports

Long-Term Effects on Clinical Outcomes of Aggressive Lowering of Low-Density Lipoprotein Cholesterol Levels and Low-Dose Anticoagulation in the Post Coronary Artery Bypass Graft Trial

Genell L. Knatterud, PhD; Yves Rosenberg, MD; Lucien Campeau, MD; Nancy L. Geller, PhD; Donald B. Hunninghake, MD; Sandra A. Forman, MA; James S. Forrester, MD; Fredarick L. Gobel, MD; J. Alan Herd, MD; Ann Hickey, MD; Byron J. Hoogwerf, MD; Michael L. Terrin, MD; Carl White, MD

From the Maryland Medical Research Institute, Baltimore (G.L.K., S.A.F., M.L.T.); Clinical Trials Group (Y.R.) and Office of Biostatistics Research (N.L.G.), NHLBI, Bethesda, Md; Montreal Heart Institute, Montreal, Quebec, Canada (L.C.); Heart Disease Prevention Clinic (D.B.H.) and Angiogram Reading Center (C.W.), University of Minnesota, and Minneapolis Heart Institute (F.L.G.), Minneapolis; Cedars-Sinai Medical Center, Los Angeles, Calif (J.S.F., A.H.); Baylor College of Medicine, Houston, Tex (J.A.H.); and Cleveland Clinic Foundation, Cleveland, Ohio (B.J.H.).

Background—The Post Coronary Artery Bypass Graft Trial, designed to compare the effects of 2 lipid-lowering regimens and low-dose anticoagulation versus placebo on progression of atherosclerosis in saphenous vein grafts of patients who had had CABG surgery, demonstrated that aggressive lowering of LDL cholesterol (LDL-C) levels to <100 mg/dL compared with a moderate reduction to 132 to 136 mg/dL decreased the progression of atherosclerosis in grafts. Low-dose anticoagulation did not significantly affect progression.

Methods and Results—Approximately 3 years after the last trial visit, Clinical Center Coordinators contacted each patient by telephone to ascertain the occurrence of cardiovascular events and procedures. The National Death Index was used to ascertain vital status for patients who could not be contacted. Vital status was established for all but 3 of 1351 patients. Information on nonfatal events was available for 95% of surviving patients. A 30% reduction in revascularization procedures and 24% reduction in a composite clinical end point were observed in patients assigned to aggressive strategy compared with patients assigned to moderate strategy during 7.5 years of follow-up, P=0. 0006 and 0.001, respectively. Reductions of 35% in deaths and 31% in deaths or myocardial infarctions with low-dose anticoagulation compared with placebo were also observed, P=0.008 and 0.003, respectively.

Conclusions—The long-term clinical benefit observed during extended follow-up in patients assigned to the aggressive strategy is consistent with the angiographic findings of delayed atherosclerosis progression in grafts observed during the trial. The apparent long-term benefit of low-dose warfarin remains unexplained.

Key Words: bypass • grafting • anticoagulation • lipids • follow-up studies

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