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Ann Thorac Surg 2001;71:1068-1069
© 2001 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Uppsala University Hospital, S-751 85, Uppsala, Sweden
e-mail: christian.olsson{at}thorax.uas.lul.se
To the Editor
In his editorial in the May 2000 issue of The Annals [1], Dr Roberts points out the importance of multimodal therapy in order to achieve optimal results of coronary artery bypass grafting (CABG). To this end, Dr Roberts cites large-scale studies implicating benefits of lipid-lowering drugs, statins in particular; antiplatelet drugs; angiotensin-converting enzyme-inhibitors (ACEI); and beta-blockers for a general "high-risk" population. Recent studies states the case for these medications even more compelling, and in some instances, with first-line evidence of therapeutic success for patients undergoing myocardial revascularization. The Atorvastatin versus Revascularization Treatment (AVERT) study showed that pronounced lowering of serum-cholesterol levels using high-dose medical treatment with the statin atorvastatin entailed a 36% reduction of ischemic events during a follow-up period of 18 months compared with percutaneous transluminal coronary angioplasty with or without concomitant stenting [2]. The authors speculate that the effect of atorvastatin is related to enhanced plaque stability and could be even more pronounced long-term. The MERIT-HF investigators studied the selective ß1-blocker metoprolol as an adjunct to standard medical heart failure therapy (ACEI in combination with a diuretic ± digoxin). Effects on mortality and morbidity were appalling, and the study was terminated prematurely after 1 year, with a relative risk reduction of 66% for death of any cause and of 51% for death from worsened heart failure [3]. The APRES study was undertaken to give evidence to the assumption that ACEI is of value in the sizeable yet hitherto unstudied population of patients with asymptomatic moderate left ventricular dysfunction undergoing CABG or percutaneous transluminal coronary angioplasty. One-hundred and fifty-nine patients were randomized to placebo or ramipiril in this double-blind study. There was a significant reduction in the composite endpoint of cardiac death, nonfatal acute myocardial infarction, or clinical heart failure (8 vs 18 patients, p = 0.031) [4]. Interestingly, ramipiril significantly reduced the incidence of cardiac death, but not the incidence of heart failure, and the treatment effect was not related to degree of left ventricular dysfunction, suggesting another effect than just improving left ventricular function. The AVERT, MERIT-HF, and APRES studies had in common reporting good tolerance and few side effects of the studied drugs. In addition to Dr Roberts editorial, these investigations suggest that: (1) aggressive lowering of serum-cholesterol may even further improve graft patency; (2) treatment with a selective ß-blocker may be implicated not only to those patients that have sustained a myocardial infarction, but also to those suffering from heart failure postoperatively; and (3) ACEI treatment is probably indicated for a large subgroup of CABG patients: those with asymptomatic, moderately reduced left ventricular function.
References
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