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Ann Thorac Surg 2000;69:1315-1316
© 2000 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
Address reprint requests to Dr Roberts, Division of Cardiothoracic Surgery, University of North Carolina School of Medicine, 108 Burnett-Womack Building, CB 7065, Chapel Hill, NC 27599-7065
e-mail: charless{at}med.unc.edu
The debate on the best form of therapy for coronary artery disease has been framed historically in terms of medicine versus surgery. Physicians and surgeons engaged in this debate often have failed to avail their patients of the potential benefit of multimodality therapy. Several modes of therapy extend survival in patients with coronary artery disease (Table 1), and they can be combined to achieve maximal benefit.
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Three major secondary preventive trials support the use of statin drugs in patients with coronary artery disease [4–6]. In the Scandinavian Simvastatin Survival Study, the simvastatin group had a 42% reduction in coronary deaths at 5.4 years compared with the placebo group [4]. In the Cholesterol and Recurrent Events (CARE) study, in which about one fourth of the patients had a previous CABG, a 24% reduction in fatal coronary events or nonfatal myocardial infarction occurred over 5 years with pravastatin compared with placebo [5]. Specifically, the survival benefit of the CABG patients taking pravastatin versus placebo was 38% [7]. In the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) study, in which about one fourth of the patients also had had CABG, a relative risk reduction of 24% in mortality rate from coronary artery disease occurred over 6 years with pravastatin [6]. Although this editorial concerns the survival benefit of statin drugs, the positive effect of lowering lipid levels on graft patency after CABG has been well demonstrated [8].
In a metaanalysis of 145 trials of antiplatelet drugs (mainly aspirin), involving about 70,000 high-risk patients with atherothrombotic diseases of various kinds, the incidence of myocardial infarction was reduced by 30% and vascular death by 17% after 2 years [9]. For patients with either acute or healed myocardial infarcts, aspirin prevented about 40 vascular events per 1,000 patients treated for 1 month or 2 years, respectively [9].
Trials of inhibitors of angiotensin-converting-enzymes have shown improved symptoms and reduced mortality rates in patients with congestive heart failure [10, 11]. More recently, the Heart Outcomes Prevention Evaluation (HOPE) study showed that ramipril (10 mg daily) reduced cardiovascular deaths by 25% and nonfatal myocardial infarction by 20% in high-risk patients, compared with matching placebo over 5 years [12]. The average blood pressure reduction was only 3/2 mm Hg, and the benefit of ramipril was independent of ejection fraction. Like the statin drugs, angiotensin-converting-enzyme inhibitors might accomplish their beneficial effect by improving systemic endothelial function [13].
Two major metaanalyses of beta-blockade after myocardial infarction have shown conclusively a reduction in cardiovascular mortality rate of approximately 23% at 5 years [14, 15]. The benefit of beta-blockade applies to patients with acute or healed myocardial infarcts, which is nearly half of all CABG patients [16].
In summary, virtually all CABG patients should probably be started on a statin drug with the goal of maintaining a low-density lipoprotein-cholesterol level of 100 mg/dL or less. Contraindications would be active liver disease or women of child-bearing age. Postoperatively aspirin should be prescribed routinely except in patients with an allergy or gastric intolerance, in which case clopidogrel can be substituted. An angiotensin-converting-enzyme inhibitor appears warranted in CABG patients with an abnormal ejection fraction and perhaps in all CABG patients, as data from the HOPE study suggests. Beta-blockers should be restricted to patients who have had a myocardial infarction and should be avoided in patients with overt congestive heart failure, heart block, or bradycardia.
Each of those five forms of therapy confers a survival benefit in patients with coronary artery disease. Although CABG is beneficial in selected patients with coronary artery disease compared with historical medical therapy, it is not the only form of therapy that can extend life. A surgeon who treats a patient with CABG has the responsibility to initiate or continue multimodality therapy while that patient is under his or her care. Incorporating risk reduction drug therapy into routine postoperative and discharge orders may reduce the frequency of reintervention and, more importantly, extend survival after CABG.
References
This article has been cited by other articles:
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  T. A. Denton, G. C. Fonarow, K. A. LaBresh, and A. Trento Secondary prevention after coronary bypass: the American Heart Association "Get with the Guidelines" program Ann. Thorac. Surg., March 1, 2003; 75(3): 758 - 760. [Full Text] [PDF]
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C. Olsson Postoperative drug therapy and survival after coronary artery bypass grafting. Ann. Thorac. Surg., March 1, 2001; 71(3): 1068 - 1069. [Full Text] [PDF]
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