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Ann Thorac Surg 2006;82:810-811
© 2006 The Society of Thoracic Surgeons
Christiana Care Health Services, 4755 Ogletown-Stanton Rd, Newark, DE 19718
(Email: wweintraub{at}christianacare.org; mbanbury{at}christianacare.org).
Despite decades of progress in preventing and treating vascular disease, it remains the most frequent cause of death in most countries of the world, both developed and developing [1, 2]. As part of the overall care of outpatients, coronary surgery has been critical in relieving angina pectoris, and in selected patients, prolonging life [3, 4]. In assessing the outcome after coronary surgery, it is critical to follow-up patients for long periods of time.
Gao and colleagues [5] have contributed to our understanding of coronary surgery by analyzing the outcome of 20,835 patients undergoing isolated coronary surgery between 1968 and 2003. The authors note an overall operative mortality of 2.5%, which has remained relatively constant since 1974. With 84% follow-up, survival at 5, 15, 25, and 35 years was 86%, 48%, 19%, and 7%, respectively. The primary predictors of long-term mortality were older age, prior myocardial infarction, hypertension, diabetes, and prior coronary artery bypass grafting.
Clinical trials have shown that coronary surgery is a good treatment for angina and can prolong life for selected patients with left main disease, multivessel disease, and abnormal left ventricular function. Randomized trials comparing coronary surgery with balloon angioplasty have been neutral or have shown that coronary surgery offers a better outcome [4, 6]. These randomized trial results are supported further by studies considering long-term outcome [7].
Notwithstanding the benefits of coronary surgery—and multiple studies do show clear benefit—there are certain limitations that must be understood. The report by Gao and colleagues considers mortality but does not consider other outcomes, including myocardial infarction, recurrent angina, and heart failure. The consideration of recurrent angina is particularly important, because it may be most important to patients to be able to function and is related to progression of disease. Similarly, heart failure is an important end point long term because it is becoming increasingly common and expensive and is associated with severe limitations in health status. We know very little about other end points in addition to mortality long term after coronary surgery.
The issue of very-long-term follow-up raises the simple question: How long it is meaningful to follow-up such patients? Atherosclerosis, a diffuse process occurring to various extents in all arterial beds, will continue to progress. Thus, vascular problems will most likely develop decades later in a patient who has undergone coronary surgery that are entirely independent of the revascularization. These include development of disease in other beds, diffuse distal disease, poor left ventricular function, as well as peripheral and cerebrovascular disease with resultant end-organ dysfunction. It is thus unrealistic to expect revascularization in one vascular bed to affect outcomes decades later.
It is also not proper to consider coronary revascularization in isolation from other forms of therapy. As noted, atherosclerosis is a diffuse disease affecting all beds. Revascularization must thus be considered in the context of appropriate lipid-lowering and antiplatelet therapies, renin-angiotensin-aldosteronism system blockade, and ß-blocker therapy. All of these therapies have been shown to be life saving and to prevent events in appropriate patients. Understanding revascularization, especially when studied over a period of decades, requires consideration of changes in the indications for and intensity of medical therapy.
Finally, coronary surgery is being performed in a changing landscape of older, sicker patients with more comorbidity, but also technical innovation with improved cardioplegia and innovative less-invasive approaches [8]. None of this has diminished the contribution of Gao and colleagues, but it does show the context into which long-term therapy must be considered. Surgical therapies as well as percutaneous coronary interventional approaches develop through iterative technical improvements over time, thus limiting our ability to extrapolate long-term outcomes from therapy offered years ago to current methods. Nonetheless, the use of results of past therapies with long-term outcome to offer an indication of outcomes of today's technology along with clinical trial evidence remain the best approaches we have to improve the practice of evidence based medicine.
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