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CLINICAL STUDIES

Relationship of extent of revascularization with angina at one year in the bypass angioplasty revascularization investigation (BARI)

Patrick L. Whitlow, MD, FACC^*, Alexios P. Dimas, MD, FACC, Thomas M. Bashore, MD, FACC, Robert M. Califf, MD, FACC, Martial G. Bourassa, MD, FACC, Bernard R. Chaitman, MD, FACC^¶, Allan D. Rosen, MS^#, Kevin E. Kip, MSPH^#, Michael L. Stadius, MD, FACC^**, Edwin L. Alderman, MD, FACC for the BARI Investigators

^* Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Department of Cardiology, Hygeia Hospital, Athens, Greece
Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
Montreal Heart Institute, Montreal, Canada
^¶ Division of Cardiology, St. Louis University Health Sciences Center, St. Louis, Missouri, USA
^# Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
^** Cardiology Division, Seattle V.A. Hospital, Seattle, Washington, USA
Division of Cardiology, Stanford University Medical Center, Stanford, California, USA

Manuscript received May 21, 1998; revised manuscript received March 29, 1999, accepted August 5, 1998.

Reprint requests and correspondence: Patrick L. Whitlow, Department of Cardiology, F25, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195
whitlop{at}ccf.org

OBJECTIVES

To determine the relative degree of revascularization obtained with bypass surgery versus angioplasty in a randomized trial of patients with multivessel disease requiring revascularization (Bypass Angioplasty Revascularization Investigation [BARI]), one-year catheterization was performed in 15% of patients.

BACKGROUND

Complete revascularization has been correlated with improved outcome after coronary artery bypass grafting (CABG) but not with percutaneous transluminal coronary angioplasty (PTCA). Relative degrees of revascularization after PTCA and surgery have not been previously compared and correlated with symptoms.

METHODS

Consecutive patients at four BARI centers consented to recatheterization one year after revascularization. Myocardial jeopardy index (MJI), the percentage of myocardium jeopardized by 50% stenoses, was compared and correlated with angina status.

RESULTS

Angiography was completed in 270 of 362 consecutive patients (75%) after initial CABG (n = 135) or PTCA (n = 135). Coronary artery bypass grafting patients had 3 ± 0.9 distal anastomoses and PTCA patients had 2.4 ± 1.1 lesions attempted at initial revascularization. At one year, 20.5% of CABG patients had 1 totally occluded graft and 86.9% of vein graft, and 91.6% of internal mammary artery distal anastomotic sites had <50% stenosis. One year jeopardy index in surgery patients was 14.1 ± 11%, 46.6 ± 20.3% improved from baseline. Initial PTCA was successful in 86.9% of lesions and repeat revascularization was performed in 48.4% of PTCA patients by one year. Myocardial jeopardy index one year after PTCA was 25.5 ± 22.8%, an improvement of 33.8 ± 26.1% (p < 0.01 for greater improvement with CABG than PTCA). At one year, 29.6% of PTCA patients had angina versus 11.9% of surgery patients, p = 0.004. One-year myocardial jeopardy was predictive of angina (odds ratio 1.28 for the presence of angina per every 10% increment in myocardial jeopardy, p = 0.002). Randomization to PTCA rather than CABG also predicted angina (odds ratio 2.19, p = 0.03).

CONCLUSIONS

In this one-year angiographic substudy of BARI, CABG provided more complete revascularization than PTCA, and CABG likewise improved angina to a greater extent than PTCA.

Abbreviations and Acronyms   BARI = Bypass Angioplasty Revascularization Investigation   CABG = coronary artery bypass grafting   LV = left ventricular   MI = myocardial infarction   MJI = myocardial jeopardy index (the estimated percentage of left ventricular myocardium supplied by arteries/bypass grafts with 50% stenosis by core laboratory assessment)   PTCA = percutaneous transluminal coronary angioplasty   RAO = right anterior oblique   TIMI = Thrombolysis In Myocardial Infarction   TVR = target vessel revascularization

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