(Circulation. 2000;102:144.)
© 2000 American Heart Association, Inc.
Editorials |
Postscripts From the Post Coronary Artery Bypass Graft Trial
The Sustained Benefit of More Aggressive Cholesterol Lowering and the Enigma of Low-Dose Anticoagulation
From the Division of Cardiology, San Francisco General Hospital, and the University of California, San Francisco School of Medicine, San Francisco, Calif.
Correspondence to David D. Waters, MD, Division of Cardiology, Room 5G1, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110. E-mail dwaters@medsfgh.ucsf.edu
Key Words: Editorials • bypass • trials
The addition of a postscript to a letter usually indicates that the writer has additional important information to impart. The new information may either reinforce the original message or contradict it and produce a quandary. The postscript from the Post-Coronary Artery Bypass Graft trial (Post-CABG) reported in this issue does both.1 At the end of the trial, after 4.3 years of treatment, it was previously reported that patients whose LDL cholesterol level had been lowered to 93 to 97 mg/dL had significantly less progression of saphenous vein bypass graft narrowing than did those who had a level of 132 to 136 mg/dL.2 The postscript demonstrates that this angiographic outcome has clinical relevance: over the next 3 years, the difference in clinical events between the groups widened dramatically, such that over the entire 7.5-year follow-up period, cardiovascular death or nonfatal infarction was reduced from 20.3% to 15.1% (P=0.03) and coronary revascularization procedures from 27.3% to 19.2% (P=0.0006) in patients with the lower LDL cholesterol levels.
The other part of the postscript provides a surprise. Low-dose anticoagulation with warfarin had no visible effect on the progression of vein graft disease and no statistically significant effect on clinical events during the trial.2 However, by 7.5 years, total mortality was reduced by 35% (P=0.008) and death or myocardial infarction by 31% (P=0.003) in the warfarin group.
These findings raise interesting questions that will be addressed in this editorial.
How Valid Are Post-Trial Results?
Properly designed and executed clinical trials provide the
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