CLINICAL STUDIES
Is a strategy of intended incomplete percutaneous transluminal coronary angioplasty revascularization acceptable in nondiabetic patients who are candidates for coronary artery bypass graft surgery?
The bypass angioplasty revascularization investigation (BARI)
Martial G. Bourassa, MD, FACCa,
Kevin E. Kip, PhD ,
Alice K. Jacobs, MD, FACC ,
Robert H. Jones, MD, FACC ,
George Sopko, MD||,
Allan D. Rosen, PhD,
Barry L. Sharaf, MD, FACC¶,
Leonard Schwartz, MD, FACC#,
Bernard R. Chaitman, MD, FACC**,
Edwin L. Alderman, MD, FACC,
David R. Holmes, MD, FACC,
Gary S. Roubin, MD, PhD, FACC,
Katherine M. Detre, MD, DR PH, FACC,
Robert L. Frye, MD, FACC for the BARI Investigators
a Department of Medicine, Montreal Heart Institute, Montreal, Canada
University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Boston Medical Center, Boston, Massachusetts, USA
Duke University Medical Center, Durham, North Carolina, USA
|| NHLBI, Bethesda, Maryland, USA
¶ Rhode Island Hospital, Providence, Rhode Island, USA
# The Toronto Hospital, Toronto, Canada
** St. Louis Hospital, St. Louis, Missouri, USA
Stanford University Medical Center, Palo Alto, California, USA
Mayo Clinic, Rochester, Minnesota, USA
Lenox Hills Hospital, New York, New York, USA
Manuscript received July 9, 1998;
revised manuscript received December 3, 1998,
accepted January 21, 1999.
Reprint requests and correspondence: Dr. Martial G. Bourassa, Research Center, Montreal Heart Institute, 5000 Bélanger Street East, Montreal, Quebec, H1T 1C8 Canada
bourassa{at}icm.umontreal.ca
OBJECTIVES
Our objective was to determine whether a strategy of intended incomplete percutaneous transluminal coronary angioplasty revascularization (IR) compromises long-term patient outcome.
BACKGROUND
Complete angioplasty revascularization (CR) is often not planned nor attempted in patients with multivessel coronary disease, and the extent to which this influences outcome is unclear.
METHODS
Before randomization, in the Bypass Angioplasty Revascularization Investigation, all angiograms were assessed for intended CR or IR via angioplasty. Outcomes were compared among patients with IR intended if assigned to angioplasty, randomized to coronary artery bypass graft surgery (CABG) versus angioplasty; and within angioplasty patients only, among patients with IR versus CR intended.
RESULTS
At 5 years, there was a trend for higher overall (88.6% vs. 84.0%) and cardiac survival (94.5% vs. 92.1%) in CABG versus angioplasty patients with IR intended. The excess mortality in angioplasty patients occurred solely in diabetic subjects; overall and cardiac survival were similar among nondiabetic CABG and angioplasty patients. Freedom from myocardial infarction (MI) at 5 years was higher in nondiabetic CABG versus angioplasty patients (92.4% vs. 85.2%, p = 0.02), yet was similar to the rate observed (85%) in nondiabetic CABG and angioplasty patients with CR intended. Five-year rates of death, cardiac death, repeat revascularization and angina were similar in all angioplasty patients with IR versus CR intended. However, a trend for greater freedom from subsequent CABG was seen in CR patients (70.3% vs. 64.0%, p = 0.08).
CONCLUSIONS
Intended incomplete angioplasty revascularization in nondiabetic patients with multivessel disease who are candidates for both angioplasty and CABG does not compromise long-term survival; however, subsequent need for CABG may be increased with this strategy. Whether the risk of long-term MI is also increased remains uncertain.
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Abbreviations and Acronyms
| | BARI | = Bypass Angioplasty Revascularization Investigation | | CABG | = coronary artery bypass graft surgery | | CR | = complete revascularization | | IR | = incomplete revascularization | | MI | = myocardial infarction |
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