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The reduction in mortality among patients suffering from myocardial infarction mainly by improving reperfusion by primary percutaneous coronary intervention (PCI) is discussed.

People admitted to a hospital with heart attack symptoms who cannot take thrombolytic drugs should have immediate coronary angioplasty or coronary bypass surgery, according to a study of 19,917 patients. The patients who had either of these two operations had a 50% lower mortality rate on average while they were hospitalized than patients who did not. Thrombolytic drugs, angioplasty, and bypass surgery are all used to open blocked coronary arteries and restore blood flow to the heart.

Surgeons can lower the cost of coronary bypass surgery by not using a heart-lung machine, according to a study of 281 patients. This machine allows surgeons to stop the heart from beating so they can work on it more effectively. However, new techniques allow surgeons to operate on a beating heart, and thus avoid the complications of the heart-lung machine. This study included patients with single- or double-vessel disease only. Further research will be needed in patients with multiple-vessel disease.

Minimally invasive bypass surgery may be better than a stent for some patients with coronary artery disease in only one artery, according to a study of 220 patients. Although surgery is more risky than placing a stent, patients who had surgery were less likely to have chest pain six months later. A stent is a small cylinder placed inside an artery to keep it open.

ABSTRACT: Patients who have disabling coronary artery disease may not be candidates for percutaneous coronary interventions or coronary artery bypass surgery. When medical therapy alone provides little or no relief, [...]

Coronary artery stenting is less expensive than coronary artery bypass surgery, but patients who receive stents will need additional treatments to keep the artery open. Stents are small cylinders that are placed inside coronary arteries to keep them open.

Patients who develop cardiogenic shock after a heart attack may benefit from procedures that open up clogged coronary arteries. Cardiogenic shock is the most common cause of death in patients who have a heart attack. Researchers randomly assigned 302 heart attack patients to receive regular medical care or emergency angioplasty or coronary artery bypass. Although 30-day mortality rates did not differ between the two groups, six-month mortality rates were lower in the group that received emergency angioplasty or coronary artery bypass.

Patients with coronary artery disease who have angioplasty appear to have similar outcomes as those who have bypass surgery. Researchers participating in the Bypass Angioplasty Revascularization Investigation (BARI) followed 1,829 patients with coronary artery disease who had either angioplasty or bypass surgery for five years. Initially, those who had angioplasty had more episodes of angina but this difference narrowed over time. Most quality of life measures were similar in both groups. However, over half the angioplasty patients required additional angioplasty compared to 6% of the bypass patients., Objective.--To compare clinical and functional status in patients who had similar 5-year survival after coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). Design.--Randomized trial of 1829 patients followed for an average 5.4 years. Participants.--Patients with multivessel coronary artery disease suitable for both CABG and PTCA and not previously revascularized. Intervention.--Coronary artery bypass grafting or PTCA within 2 weeks after randomization. Outcome Measures.--Symptoms, exercise test results, medication use, and quality-of-life measures collected at 4 to 14 weeks, and at 1, 3, and 5 years after randomization. Analysis.--Intention to treat. Results.--Differences in angina-free rates between patients assigned to PTCA and CABG decreased from 73% vs 95% at 4 to 14 weeks (P Conclusions.--The narrowing of treatment differences in angina and exercise-induced ischemia rates can be attributed to a return of symptoms among patients assigned to CABG and incremental surgical procedures among patients assigned to PTCA. Patients assigned to PTCA apparently were able to tolerate higher rates of residual ischemia as evidenced by comparable quality of life and 5-year survival. JAMA. 1997;277:715-721

Percutaneous transluminal coronary angioplasty (PTCA) appears to result in 5-year survival rates that are similar to bypass surgery in patients with coronary artery disease in more than one artery. Five-year survival rates were 89.3% in 914 patients with multivessel disease who received bypass surgery and 86.3% in 915 patients who received angioplasty. However, within one year of treatment, 42% of the angioplasty group required further treatment compared to only 3% of those receiving bypass surgery. At 5 years the rates were 54% and 8%, respectively. Almost one-third of those who had angioplasty eventually had to have bypass surgery.

The analysis and publication of data on mortality from coronary-artery bypass grafting (CABG) at different New York hospitals and by different surgeons has led to improvements in surgical programs and patient outcome. In 1989 the New York State Department of Health created a registry of patients having CABG and published risk-adjusted mortality rates. When this data was published in a newspaper health care professionals were concerned that the public would misinterpret the data and overeact, avoiding certain hospitals and surgeons. There was also concern that the risk adjustment was not accurate, which would cause hospitals to avoid high-risk patients. However, evidence does not show that patients and hospitals reacted as such. Rather, the risk-adjustment appeared accurate and the data, and its publication, had the intended effect of leading to improvements in care. Partly because of the registry, the mortality following CABG in New York declined by 41% during the first four years of the registry's existence. The registry led to the reduction of surgeons who performed the procedure infrequently and a change in the treatment program at one hospital.

Coronary-artery bypass patients with internal-thoracic-artery (ITA) grafts appear to survive longer compared to patients with a saphenous-vein graft. Although the ITA graft has produced lower rates of disease recurrence, the vein graft has been used more often. Researchers surveyed 15 institutions to compare the survival of 749 patients with ITA bypass grafts and 4,888 patients with saphenous-vein grafts. Survival rates were consistently higher in the patients with an ITA graft throughout the 15-year follow-up period. An accelerated decline in survival of patients with a vein graft was apparent after eight years. The ITA graft had a more important influence on long-term survival than the progression of coronary disease. Patients with adverse risk factors also benefitted from ITA grafts.

Coronary artery bypass grafting (CABG) seems to improve the survival rate and physical functioning of patients with moderate to severe heart failure and chest pain. Researchers reviewed 134 studies that evaluated CABG and 12 studies that evaluated angioplasty for the treatment of moderate to severe heart failure. All studies were published between 1966 and 1993. Results revealed that CABG reduced the three-year death rate in heart-failure patients with chest pain by 30% to 50%. The functional status of heart-failure patients seemed to improve after CABG. During the CABG procedure, the patient death rate ranged from 5% to 30% depending upon patient characteristics, disease severity, and the quality of the medical center. The benefits of CABG in heart failure patients who do not have chest pain remain unclear. The effectiveness of angioplasty as an alternative to CABG or medical management has not been assessed, although the significant patient risks that accompany angioplasty are well-recognized., Objective.--This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. Data Sources.--Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty. Study Selection.--All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed. Data Extraction and Synthesis.--Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws. Conclusion.--Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting. (JAMA. 1994; 272:1528-1534)

Coronary heart disease patients who undergo coronary artery bypass grafting (CABG) appear to need fewer repeat procedures during the first year after surgery than patients who have percutaneous transluminal coronary angioplasty (PTCA). Researchers studied 337 patients with coronary artery disease in more than one artery. CABG was performed on 161 patients while the other 176 patients were treated with PTCA. The patients were then followed for one year. From hospitalization through the follow-up, five CABG patients and three PTCA patients died. During this same time period, 13 CABG patients and seven PTCA patients had heart attacks. Six percent of CABG patients and 44% of the PTCA group required additional surgery during the follow-up period. At the one-year follow-up, 74% of CABG patients and 71% of PTCA patients did not have chest pain. Patients in both groups had an improved capacity for exercise and 22% of the CABG group and 12% of the PTCA group no longer required chest-pain medication.

Patients with multivessel coronary heart disease who are treated with percutaneous transluminal coronary angioplasty (PTCA) seem to have similar rates of subsequent heart attacks and death as those treated with coronary artery bypass grafting (CABG). However, significantly more PTCA patients require further surgery. Researchers studied 392 patients with coronary artery disease in more than one artery. PTCA was performed on 198 patients while the other 194 patients had CABG. Within three years after the procedure, approximately 6% of CABG patients and 7% of CABG patients had died. Approximately 20% of PTCA patients and 15% of CABG patients had a heart attack during follow-up. Decreased blood supply to areas of the heart was noted in approximately 10% of PTCA patients and 6% of CABG patients. The type of treatment did impact the rates of additional vascular surgery. Fifty-four percent of PTCA patients and 13% of CABG patients had additional heart-vessel surgery during the follow-up period.

Coronary angiography and coronary artery bypass graft (CABG) surgery tend to be used appropriately in heart disease patients in Canada and the U.S. Researchers reviewed medical records of 1866 coronary angiography patients, 533 treated in Canada and 1333 treated in New York, and 1892 CABG patients, 556 treated in Canada and 1336 treated in New York. Investigators assessed the appropriateness and short-term outcome of the procedure in each patient. Results revealed that coronary angiography was used inappropriately in 5% of Canadians and 4% of New Yorkers according to U.S. criteria. CABG was used inappropriately in 3% in Canadians and 2% of New Yorkers according to U.S. criteria. Both procedures were performed less often in Canadian patients over age 75 than in their New York counterparts. Patient outcome after coronary angiography revealed that more New Yorkers had less significant blockage of their arteries than Canadians. During CABG, more Canadians had a heart attack than New Yorkers., Objective.--To compare the appropriateness of coronary angiography and coronary artery bypass graft (CABG) use between the United States and Canada. Design.--Retrospective randomized medical record review. Setting.--All hospitals performing coronary angiography and/or CABG surgery in two Canadian provinces (Ontario and British Columbia); in New York State, 15 randomly selected hospitals that provide coronary angiography and 15 randomly selected hospitals that provide CABG surgery. Patients.--All patients were randomly selected. For coronary angiography, 533 patients in Canada and 1333 patients in New York were selected; for CABG, 556 patients in Canada and 1336 patients in New York were selected. Main Outcome Measures.--Percentage of patients in each country who had coronary angiography or CABG for necessary, appropriate, uncertain, or inappropriate indications as rated by criteria developed separately in each country and the complications of those procedures. Results.--For coronary angiography, 9% of Canadian cases and 10% of New York cases were rated inappropriate using Canadian criteria compared with 5% and 4%, respectively, using US criteria. For CABG, 4% of Canadian cases and 6% of New York cases were rated inappropriate by Canadian criteria compared with 3% and 2%, respectively, using US criteria. A lower proportion of procedures were performed on persons aged 75 years or older in Canada than in New York for both coronary angiography (5% vs 11%; P

Coronary artery bypass grafting is now a relatively common procedure used to replace critical heart arteries that are defective. A comparison of the mortality rate of this serious surgical procedure among five teaching hospitals in Philadelphia was conducted to identify factors that might be altered to improve the survival rate. The study found that there were significant differences among the medical centers in the death rate. These differences were limited to patients who required catheterization during the surgical procedure. Such patients are, in general, more seriously ill than the patients who do not require catheterization. However, the differences among the hospitals could not be explained by differences in the severity of illness of the patients. Rather, there were indications that the variations may be due to the skills of the surgeons involved. During the course of the study, some of the mortality rates of the medical centers changed, and these changes correlated with the movement of specific surgeons from one medical center to another. There was some indication that hospitals performing an increasing number of grafting procedures may enjoy a decrease in the mortality rate, perhaps as a result of increased experience on the part of the hospital staff. This correlation is not conclusive, however. The results of this study indicated that, although more seriously ill patients were more likely to die, differences in the mortality rates among different hospitals and among different surgeons cannot be attributed to patient differences alone. Further study of these differences may reveal ways in which the mortality rate from coronary artery bypass grafting may be improved. (Consumer Summary produced by Reliance Medical Information, Inc.), Sankey V Williams, MD; David B. Nash, MD, MBA; Neil Goldfarb Objective.-To measure hospital- and surgeon-specific mortality rates for patients with coronary artery bypass graft (CABG) surgery and to examine possible reasons for any differences. Design. -Cohort study using hospital discharge abstracts and itemized bills. Setting.-Five major teaching hospitals in Philadelphia, Pa. Patients. -Consecutive sample of all 4613 patients over a 30-month period. Main Outcome Measure. - in-hospital mortality rates. Results.-We observed differences in hospital mortality rates for patients who underwent coronary artery catheterization and CABG surgery during the same admission (diagnosis related group 106) but not for patients who underwent only CABG surgery during the admission (diagnosis related group 107). There were threefold differences in surgeon-specific mortality rates. The hospital mortality rates for coronary artery catheterization and CABG surgery during the same admission changed during the study and coincided with moves of surgeons among study hospitals. Our measures of illness severity did identify patients who were more likely to die, but differences in severity of illness did not explain differences in hospital- or surgeon-specific mortality rates. Patient mortality rates were not associated with the volume of procedures performed by individual surgeons. We found inconclusive evidence for an association with surgeons' clinical skills, and, to a lesser extent, with the hospital's volume of procedures and the hospital's organization and staffing. A greater intensity of hospital services was not necessary for a lower mortality rate. Conclusions.-We conclude that studies of CABG mortality should examine mortality rates by diagnosis related group, collect data from more than 1 year, examine associations with surgeons? clinical skills, include information on hospital organization and staffing, and cautiously explore more efficient ways of providing care. (JAMA. 1991;266:810-815)

The surgical technique of coronary artery bypass grafting is performed in many medical centers to replace important heart arteries that have been affected by arteriosclerosis. The death rate of patients varies widely among these hospitals. However, this does not necessarily mean that hospitals with better survival rates are better hospitals. Some hospitals with lower survival rates may treat a higher proportion of patients who are older or frail, or may cater to poorer patients who have suffered from a lifetime of inferior medical care. Nevertheless, any suggestion that death rates might be higher than necessary must be investigated carefully. For this reason, the results of bypass graft surgery performed on 3,055 patients at five medical centers were compared with careful reference to all factors that might potentially influence the outcome such as age, sex, body size, and general condition of the heart. It was found that the five medical centers, all located in New England, included in the present study treated a mix of patients that was relatively comparable. This contrasts with some other studies of more widely distributed medical centers. While the overall rate of mortality from the grafting procedure was 4.3 percent, from center to center the rate ranged from 3.1 percent to 6.3 percent. The variation among the 18 surgeons involved was even greater, ranging from 1.9 percent to 9.2 percent mortality. These differences cannot be completely accounted for simply on the basis of patient differences, and seem to be the result of differences that have not yet been identified. Although the present study found that the variations in mortality rates among the medical centers could not be accounted for by patient differences, it cannot be concluded that the overall mortality rate of a medical center is an accurate measure of the center's quality of treatment. (Consumer Summary produced by Reliance Medical Information, Inc.), Objective.-A prospective regional study was conducted to determine if the observed differences in in-hospital mortality rates associated with coronary artery bypass grafting (CABG) are solely the result of differences in patient case mix. Design.-Regional prospective cohort study Data including patient demographic and historical data, body surface area, cardiac catheterization results, priority of surgery, comorbidity, and status at hospital discharge were collected. This study presents data for 3055 CABG patients between July 1, 1987, and April 15,1989. Setting. -This study includes data from all surgeons performing cardiothoracic surgery in Maine, New Hampshire, and Vermont; the datawere collected from five regional medical centers. Patients.-Data were collected from all consecutive isolated CABG surgery patients during the study period. Main Outcome Measures.-Crude and adjusted in-hospital mortality rates associated with CABG. Main Results.-The overall crude in-hospital mortality rate for isolated CABG was 4.3%. The rate varied among centers (range, 3.1 % to 6.3%) and among surgeons (range, 1.9% to 9.2%). Predictors of in-hospital mortality included increased age, female gender, small body surface area, greater comorbidity, reoperation, poorer cardiac function as indicated by a lower ejection fraction, increased left ventricular end diastolic pressure, and emergent or urgent surgery. After adjusting for the effects of potentially confounding variables, substantial and statistically significant variability was observed among medical centers (P =.021) and among surgeons (P =.025). Conclusion. - We conclude that the observed differences in in-hospital mortality rates among institutions and among surgeons in northern New England are not solely the result of differences in case mix as described by these variables and may reflect differences in currently unknown aspects of patient care. Understanding this variation requires a detailed understanding of the processes of care.

Coronary artery bypass surgery is used to treat patients with severe atherosclerosis - the hardening build-up of fatty plaques - in multiple coronary arteries. It is important to assess the extent of residual ischemia (poor blood flow) after surgery, and most techniques rely on analysis of exercise-induced blood flow changes, which is not appropriate for patients immediately after surgery. Dipyridamole is a drug that increases coronary blood flow and dilation of blood vessels, but has little effect in ischemic areas. It has been used in combination with echocardiography (ultrasound imaging of the heart) to detect myocardial (heart muscle) ischemia. The effectiveness of dipyridamole plus transesophageal echocardiography (in which the ultrasound probe is placed in the esophagus) in assessing residual ischemia two hours after bypass surgery was studied in 11 male patients. Results were compared with those obtained after one week from a dipyridamole-transthoracic echocardiography (where the probe is placed on the chest exterior) stress test. The postsurgical stress test showed that six patients obtained normalization of blood flow and function, three patients had abnormal heart contraction reversed following surgery, while in two, abnormalities persisted. The study provides preliminary evidence that the dipyridamole echocardiographic stress test can evaluate patients' conditions and validate the function of grafted arteries after coronary bypass surgery. (Consumer Summary produced by Reliance Medical Information, Inc.)

A group of patients who have had mild angina or heart attack (myocardial infarction, MI) without subsequent angina was followed for 10 years. The five-year survival rate for these patients, who were treated either medically (by drug therapy) or by surgery (with bypass procedures) has previously been reported. Among the group of 407 medically treated patients, there was a survival rate of 77 percent; 127 of the patients required cardiac surgery at some point. Surgically treated patients had an overall survival rate of 83 percent, but the group given vein grafts had a 76 percent rate, while those with artery grafts had a 91 percent survival rate. The survival rates of patient subgroups, defined by such factors as disease of one or several coronary arteries or degree of artery narrowing, are described. Cardiac events (fatal or nonfatal) occurred among 53 percent of medical patients and 22 percent of surgical patients, a significant difference. Among medically treated patients there were 73 cardiac and 21 noncardiac deaths, while among surgically treated patients, there were 40 cardiac deaths and 14 non-cardiac deaths. The study suggests that surgical treatment of mild coronary artery disease provides a better prognosis than does medical treatment, especially if the bypass is done with an arterial graft. (Consumer Summary produced by Reliance Medical Information, Inc.)