INVASIVE AND INTERVENTIONAL CARDIOLOGY
Native coronary disease progression exceeds failed revascularization as cause of angina after five years in the bypass angioplasty revascularization investigation (BARI)
Edwin L. Alderman, MD, FACC,*,*,
Kevin E. Kip, PhD, ,
Patrick L. Whitlow, MD, FACC, ,
Thomas Bashore, MD, FACC, ,
Donald Fortin, MD,,
Martial G. Bourassa, MD, FACC,||,
Jacques Lesperance, MD,||,
Leonard Schwartz, MD, FACC,¶ and
Michael Stadius, MD, FACC#
* Cardiovascular Division, Stanford University, Stanford, California
Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
Cleveland Clinic, Cleveland, Ohio
Cardiology Division, Duke University, Durham, North Carolina
|| Montreal Heart Institute, Montreal, Canada
¶ Toronto General Hospital, Toronto, Canada
# University of Washington, Seattle, Washington
Manuscript received June 30, 2003;
revised manuscript received April 23, 2004,
accepted May 4, 2004.
* Reprints requests and correspondence: Edwin L. Alderman, Stanford University Medical Center, Cardiovascular Medicine CVRC-261, Stanford, California 94305 (Email: alderman{at}stanford.edu).
OBJECTIVES: Coronary angiograms obtained five years following revascularization were examined to assess the extent of compromise in myocardial perfusion due to failure of revascularization versus progression of native disease.
BACKGROUND: The Bypass Angioplasty Revascularization Investigation (BARI) randomized revascularization candidates between bypass surgery and angioplasty. Entry and five-year angiograms from 407 of 519 (78%) patients at four centers were analyzed.
METHODS: Analysis of the distribution of coronary vessels and stenoses provided a measure of myocardial jeopardy that correlates with presence of angina. The extent to which initial benefits of revascularization were undone by failed revascularization versus native disease progression was assessed.
RESULTS: Myocardial jeopardy fell following initial revascularization, from 60% to 17% for percutaneous coronary intervention (PCI)-treated patients compared with 60% to 7% for coronary artery bypass graft (CABG) surgery patients (p < 0.001), rebounding at five years to 25% for PCI and 20% for surgery patients (p = 0.01). Correspondingly, angina prevalence was higher at five years in PCI-treated patients than in surgery-treated patients (28% vs. 18%; p = 0.03). However, myocardial jeopardy at five years, and not initial treatment (PCI vs. surgery), was independently associated with late angina. Increased myocardial jeopardy from entry to five-year angiogram occurred in 42% of PCI-treated patients and 51% of CABG-treated patients (p = 0.06). Among the increases in myocardial jeopardy, two-thirds occurred in previously untreated arteries.
CONCLUSIONS: Native coronary disease progression occurred more often than failed revascularization in both PCI- and CABG-treated patients as a cause of jeopardized myocardium and angina recurrence. These results support intensive postrevascularization risk-factor modification.
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Abbreviations and Acronyms
| | BARI = Bypass Angioplasty Revascularization Investigation | | CABG = coronary artery bypass graft surgery | | CHC = Canadian Heart Classification | | CI = confidence interval | | LV = left ventricle/ventricular | | OR = odds ratio | | PCI = percutaneous coronary intervention | | TIMI = Thrombolysis In Myocardial Infarction |
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