Selection of patients for direct myocardial revascularization

Abstract

The high incidence of ischemic heart disease and its associated mortality, morbidity, and socioeconomic implications have stimulated a great deal of interest and controversy regarding the relative roles of surgical and medical therapy. There is general agreement that stable angina pectoris can be substantially improved or relieved by coronary artery bypass grafting in at least 80% of patients, and that stable angina not responding to medical treatment is a firm indication for this procedure if adequate distal vessels for grafting are present. The effect of myocardial revascularization on longevity in stable angina patients is not certain except in the presence of significant obstruction of the left main coronary artery, where improved prognosis has been demonstrated. Evidence appears to be accumulating that surgical treatment improves prognosis in disease involving 3 vessels and 2 vessels, particularly if reversible left ventricular dysfunction is present. The prognosis in single-vessel coronary artery disease does not appear to be influenced by surgical therapy.Unstable angina pectoris appears to be best managed initially by intensive medical therapy and coronary angiography, with urgent surgery being done for significant left main coronary artery disease or uncontrolled angina, and elective surgery being done for multiple-vessel disease. Coronary artery bypass grafting for acute myocardial infarction remains of limited value unless complications such as cardiogenic shock occur, when the prognosis may be somewhat improved by an early aggressive surgical approach in selected cases.Improved selection of patients for direct myocardial revascularization in the future appears to depend on the de-