(Circulation. 1995;91:2325-2334.)
© 1995 American Heart Association, Inc.
Articles |
Comparison of Surgical and Medical Group Survival in Patients With Left Main Coronary Artery Disease
Long-term CASS Experience
Presented in part at the American College of Cardiology 42nd Annual Scientific Session, March 16, 1993, Anaheim, Calif, and published as an abstract (J Am Coll Cardiol. 1993;21:455A).
From the St Louis (Mo) University Health Sciences Center (E.A.C., G.C.K., B.R.C.); the University of Washington (K.B.D., S.D.C.), Seattle; the National Heart, Lung, and Blood Institute (G.S.), Bethesda, Md; the Mayo Clinic and Mayo Foundation (H.S.), Rochester, Minn; and the University of Alabama Medical Center (H.A.T.), Birmingham.
Background Observational and randomized studies designed to compare surgical and medical therapies in patients with left main coronary artery disease (LMCD) have shown that coronary artery bypass graft (CABG) surgery prolongs life in most patients with LMCD. The present report of 1484 patients with LMCD in the Coronary Artery Surgery Study (CASS) Registry extends the originally published 5-year surgical and medical group survival analysis to more than 16 years of follow-up and permits analysis of LMCD patient subgroups.
Methods and Results The CASS Registry contains 1484 patients with
50% left main coronary artery stenosis initially treated with either
surgical or nonsurgical therapy. The 15-year cumulative survival
estimates were 37% for the 1153 patients in the surgical group
compared with 27% for the 331 patients in the medical group. Median
survival in the surgical group was 13.3 years (12.8 to 13.8 years, 95%
confidence limits) compared with only 6.6 years (5.4 to 7.9 years) in
the medical group (difference, 6.7 years; P<.0001). Median
survival was also significantly longer in the surgical group stratified
by age, sex, anginal class, left ventricular (LV) function, coronary
anatomy, and the extent of LMCD. However, CABG surgery did not
significantly prolong median survival in patient subgroups with (1)
left main coronary stenosis of 50% to 59%; (2) normal LV systolic
function; (3) normal or mildly abnormal LV systolic function and a
right coronary artery stenosis 70%; and (4) a nonstenotic (
70%)
right coronary artery. The 15-year cumulative survival for patients
with normal LV systolic function in the surgical and medical
groups was 42% and 51%, respectively. Median survival was 14.7 years
in the surgical group and >15 years in the medical group
(P=NS). In patients with normal LV systolic function and a
right coronary artery stenosis 70%, the 15-year cumulative survival
rates were also similar in the surgical and medical groups (40% and
48%, respectively). Median survival was 14.3 years in the surgical
group and 14.2 years in the medical group (P=NS). The
15-year cumulative survival estimates for all subgroups were affected
by convergence of the surgical and medical survival group curves owing
to a disproportionate increase in the late surgical group mortality.
Overall, 25% of patients in the medical group ultimately underwent
CABG surgery. If all medical group patients had survived long enough,
about 47% would be estimated to have had surgery by 15 years.
Conclusions This report, which extends follow-up of more than 16
years in CASS Registry patients with LMCD, shows that CABG surgery
prolongs life in most clinical and angiographic subgroups. However,
median survival was not prolonged by CABG surgery in patients with
normal LV systolic function, even if a significant right coronary
artery stenosis (70%) also was present. These results extend our
understanding of the natural history of LMCD and permit a more accurate
estimate of long-term surgical and medical group survival.
Key Words: coronary disease • bypass • surgery
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