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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.

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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