Medical compared with surgical management of unstable angina. 5-year mortality and morbidity in the Veterans Administration Study.

Abstract

We evaluated medical in comparison to surgical plus medical (surgical) Compared with results at 24 months, this 60-month follow-up study showed important differences in survival for patients with three-vessel disease: 75% for medical and 89% for surgical patients (p<0.02). The cumulative 5-year rate of repeat hospitalizations for cardiac reasons was less with surgical patients for either clinical presentation. For type 1, medical patients had a 56%o rate, and surgical patients had a 42% rate (p=0.004). For type 2, medical patients had a 62% rate, and surgical patients had a 43% rate (p=0.05). Overall mortality did not differ between the two treatments, and this remained true in type 1 versus type 2 patients and in those with normal versus abnormal LV function. However, regression analysis of medical and surgical groups with ejection fraction as a continuous variable showed that mortality of medical patients depended on ejection fraction (p=0.004), whereas the mortality of surgical patients did not (p=0.76), and survival in the surgical group was higher in the lowest ejection fraction tercile-73% for medical and 86% for surgical patients, p=0.03. We conclude that surgery improves survival in patients with three-vessel disease and leads to fewer subsequent hospitalizations for cardiac reasons. An impaired ejection fraction had an adverse impact on survival of medical patients but not on surgical patients, and mortality in surgical patients was improved compared with medical patients in the lowest ejection fraction tercile. (Circulation 1989;80:1176-

Ten year mortality in patients with suspected acute myocardial infarction

“…20,21 Patients who fulfilled two criteria for infarction (possible infarction)18 have an impaired prognosis, with a first year mortality of 12%22 and a five year mortality of about 20%,3 but the annual standardised mortality ratio in these patients did not differ significantly from that in the patients who fulfilled only one criterion (fig 2). Another subgroup with increased risk is patients with unstable angina, with a first year mortality of 9%,23 and a five year mortality of 25% 24. This is close to the mortality in patients with confirmed infarction, but the subgroup with unstable angina is small, about 10% of all patients without infarction, 12,22 and the high mortality in the entire group without infarction cannot be explained solely by an increased mortality in patients with unstable angina.…”

Risk Factors Related to the 7-Year Prognosis for Patients Suspected of Myocardial Infarction with and without Confirmed Diagnosis

“…Patients with unstable angina w'ith a re ported I-year mortality of 9-16% may con tribute heavily to the poor prognosis of the non-AMI patients [15,16], However, since patients who initially had unstable angina and later during admission developed an AMI were classified as AMI patients [11], and since the patients with transient ST-T changes, i.e. patients with unstable angina, during follow up accounted for only 19% of the total num ber of cardiac events (table 1), and unfavor able prognosis for a subgroup of patients with unstable angina docs not explain the poor prognosis of the non-AMI group as a whole.…”

Unstable angina

“…• Surgical treatment of three-vessel coronary artery disease improves 5-year survival and lowers the number of repeat hospitalizations necessary compared with medical treatment in patients with stable and unstable angina [61]. The VANQWISH trial results emphasized concerns about the timing of coronary artery bypass grafting.…”