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(Circulation. 1997;96:2121-2123.)
© 1997 American Heart Association, Inc.

Articles

Is It Important How One Dies?

Questions for Planning Future Revascularization Trials

Spencer B. King, III, MD

From Andreas Gruentzig Cardiovascular Center, Emory University, Atlanta, Ga.

Correspondence to Spencer B. King III, MD, Andreas Gruentzig Cardiovascular Center, Emory University, 1364 Clifton Rd, Suite F606, Atlanta, GA 30322.

Key Words: Editorials • angioplasty • revascularization • myocardial infarction • mortality

	Introduction

 
The randomized trials of angioplasty versus coronary bypass surgery conducted to date have not shown a difference in survival, either individually or collectively.^{1 2 3} Although total mortality in the largest trial, BARI, remains nonsignificant at 5 years, for the first time a difference in cardiac mortality has emerged. In this issue of Circulation, the BARI investigators report excess mortality in the angioplasty randomized cohort (8.0% versus 4.9% for the surgical group, for a relative risk of 1.55; P=.022).⁴ The authors also report the occurrence of MI and speculate on the impact of MI on cardiac mortality.

Clearly, the most striking finding in this study is the superiority of freedom from cardiac death in the surgery group without excess noncardiac death. Further analysis of this landmark study shows that the difference in cardiac deaths is completely explained by an excess of cardiac deaths in the diabetic patients in the trial. There are more than three times as many cardiac deaths in the diabetic patients treated with angioplasty as in those patients treated with surgery. The present study concentrates on the 81% of BARI patients who did not have treated diabetes in whom no difference in cardiac mortality rate was found (4.6% for PTCA versus 4.2% for CABG; P=.09).

Two questions regarding cardiac mortality come to mind. Should cardiac mortality replace total mortality as the primary end point in comparative revascularization trials? What is the explanation for the high cardiac mortality rate in the diabetic patients? The question of whether . . . [Full Text of this Article]