Unstable angina pectoris: National cooperative study group to compare surgical and medical therapy: III. Results in patients with S-T segment elevation during pain

A prospective randomized study comparing intensive medical therapy with urgent coronary bypass surgery for the acute management of patients with unstable angina pectoris was carried out by nine cooperating medical centers under the auspices of the National Heart, Lung, and Blood Institute. Between 1972 and 1976, a total of 288 patients were entered into the study; 79 of these (27 percent of the total study group) with 70 percent or more fixed obstruction in one or more coronary arteries had episodes of pain at rest associated with transient S-T segment elevation. Forty-two were randomized to medical and 37 to surgical therapy. The hospital mortality rate was 4.8 percent for the medical and 5.4 percent for the surgical group (difference not significant). The rate Of in-hospital myocardial infarction was 12 percent in the medical and 14 percent in the surgical group (difference not significant).During the 1st and 2nd years of follow-up, 25 percent in the medical and 15 percent in the surgical group complained of New York Heart Association class III or IV angina (difference not significant). During an average follow-up period of 42 months 45 percent of the medically treated patients later underwent surgery to relieve unacceptable angina. In the medical group 65 percent were working full- or part-time at the end of 1 year and 61 percent at the end of 2 years of follow-up; comparable figures for the surgically treated group were 63 and 68 percent.The results indicate that patients with unstable angina pectoris with transient S-T segment elevation during pain at rest with fixed obstruction of 70 percent or more in one or more coronary arteries do not differ significantly from patients with pain at rest associated with transient S-T segment depression or T wave inversion. The condition of such patients can be stabilized, and they can be managed with a maximal medical program including propranolol and long-acting nitrates in pharmacologic doses with good control of pain in most and no increase in rate of early mortality or myocardial infarction. Later, elective surgery can be performed with a lower risk and good clinical results if the patient's angina fails to respond to intensive medical therapy.     

Unstable angina: comparison of medical and surgical management.

Medical versus surgical treatment of unstable angina was compared in a prospective nonrandomized study of 118 patients. Acute transient ST-T wave changes were present during chest pain in all patients. Acute infarction was excluded by serial electrocardiograms and enzyme studies. All patients admitted to the coronary care unit from 1970 to 1975 who fulfilled the entry criteria were included in the study. The starting point for data evaluation was 5 days after hospital admission. Characteristics at entry were similar in 66 medically treated patients and 52 patients who had coronary bypass vein graft surgery. During a mean follow-up period of 23 months in 66 medically treated patients with unstable angina the incidence rate of nonfatal myocardial infarction was 17% and the total mortality rate 21 percent compared with respective rates of 19% and 5.8% in 52 surgically treated patients. In the surgical group 8 patients (15%) had a perioperative infarction and only 2 (4%) had a late infarction; one patient (2%) died at operation. Symptomatic improvement was observed more frequently in the surgically treated group. Sixty percent of surgically treated patients were free of angina compared with 21% of medically treated patients. Eight medically treated patients (12%) required late surgical treatment for persistent severe angina despite optimal medical management.     

Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function

Late survival and freedom from myocardial infarction were determined for 192 patients with coronary artery disease and depressed left ventricular ejection fraction at rest (less than or equal to 35%) determined by biplane angiography who were evaluated between 1970 and 1977. Seventy-seven patients had coronary artery bypass grafting and 115 patients were treated medically and were considered surgical candidates. The medical and surgical groups were comparable in all baseline characteristics examined except frequency of three vessel disease and angina pectoris, which occurred in a significantly greater percent of the surgically treated patients (p less than 0.01). Only three medically treated patients (2.6%) underwent coronary bypass grafting in the follow-up period. Seven year actuarial survival was 63% in the surgical and 34% in the medical group (p less than 0.001). Ninety-three percent of patients in the surgical group and 81% of those in the medical group were free of nonfatal myocardial infarction (p = 0.01), and 62 and 33%, respectively, were alive and free of myocardial infarction (p less than 0.001) at 7 years. Significant differences in survival favoring surgical treatment were observed for the subsets of patients with an ejection fraction of 25% or less (p = 0.0002) and 26 to 35% (p = 0.01), and for the subsets with three vessel coronary disease (p less than 0.001), normal left ventricular end-diastolic volume (less than or equal to 100 ml/m2) (p = 0.005) and elevated end-diastolic volume (greater than 100 ml/m2)(p = 0.001). After adjustment for other important prognostic variables, the type of treatment remained significant in predicting the relative risk (medical to surgical) of mortality at 5 and 7 years (2.58 and 2.12, respectively). These data corroborate the trends observed in several randomized trials of medical and surgical therapy in patients with abnormal left ventricular function. If hospital mortality for coronary artery bypass grafting is less than 5%, substantial benefit can be anticipated for the majority of patients with depressed ventricular function.     

Medical versus surgical treatment of unstable angina

A prospective, nonrandomized data bank study of the effect of medical versus surgical management of patients with unstable angina included all patients with unstable angina seen at 1 hospital over an 8 year period. Patients were entered into the study after an initial 5 day period of medical treatment. Entry characteristics were similar in 104 surgical patients and 124 medical patients. The mean follow-up period was 52 months. The operative mortality rate was 2% (2 of 104). The incidence of operative infarction was 13% (13 of 104). Twentyseven medical patients (22%) had late surgery for progressive angina without operative mortality. Seven year survival (Mantel-Haenszel) was 65% for the medical group and 85% for the surgical group when analyzed by initial treatment (p = 0.012). Analysis by the crossover method where crossover medical patients are followed up only to the date of surgery yielded similar results (p = 0.008). Nonsurvivors were compared with survivors and had a higher incidence of the following entry characteristics: (1) age greater than 60 years; (2) diastolic blood pressure greater than 89 mm Hg; (3) ST-T changes in the resting electrocardiogram; (4) 3 vessel disease; (5) elevated left ventricular diastolic pressure (at rest); and (6) elevated left ventricular diastolic pressure (exercise). None had single vessel disease. The incidence of infarction (fatal and nonfatal) in 5 years was 17% in the medical group and 22% in the surgical group. In the latter group 13% had a perioperative infarct and 9% had a late infarct. Symptom relief was greater in the surgical group. At 5 years 62% had no angina and only 8% had severe angina compared with 37% and 24%, respectively, in the medical group. Thus surgical management of selected patients with unstable angina appears preferable to medical therapy in view of improved survival and greater symptom relief. Whereas the total incidence of infarction was not reduced this was, in part, related to a 13% incidence of perioperative infarction. Improved methods of myocardial protection have since reduced this incidence to 3.0% in our hospital.     

Ten year follow up of patients with single vessel coronary artery disease that was suitable for percutaneous transluminal coronary angioplasty

The 10 year outcome of patients with single vessel coronary artery disease who underwent coronary angiography more than 10 years before and who would have been potential candidates for percutaneous transluminal coronary angioplasty had it been available then is reported. Long term follow up data were obtained in 96 (91 men, five women; mean age 48 years) of 105 consecutive patients with single vessel coronary artery disease (greater than 70% stenosis), judged suitable for coronary angioplasty. Fifty patients had coronary bypass surgery within six months of catheterisation (surgical group) and 46 were treated medically (medical group). At entry to the study more patients in the surgical group had unstable angina, but fewer had a previous history of myocardial infarction. Ten year survival was 91% and remained excellent in all the subsets analysed. Moreover, the quality of life of these patients was good. Over the 10 year follow up, 16 (36%) of the patients treated medically and 13 (26%) in the surgical group were admitted to hospital because of cardiovascular events (including late coronary surgery in four of the patients treated medically). Lastly, 54/69 (78%) of the patients who were employed before catheterisation resumed work and 29 (42%) were still employed 10 years later. Although these data must be interpreted with care because of the limitations inherent in all retrospective studies, it appears that the long term results of conventional medical or surgical treatment are excellent in patients with single vessel coronary artery disease in whom percutaneous transluminal coronary angioplasty is now an option.     

Ten year follow up of patients with single vessel coronary artery disease that was suitable for percutaneous transluminal coronary angioplasty.

The 10 year outcome of patients with single vessel coronary artery disease who underwent coronary angiography more than 10 years before and who would have been potential candidates for percutaneous transluminal coronary angioplasty had it been available then is reported. Long term follow up data were obtained in 96 (91 men, five women; mean age 48 years) of 105 consecutive patients with single vessel coronary artery disease (greater than 70% stenosis), judged suitable for coronary angioplasty. Fifty patients had coronary bypass surgery within six months of catheterisation (surgical group) and 46 were treated medically (medical group). At entry to the study more patients in the surgical group had unstable angina, but fewer had a previous history of myocardial infarction. Ten year survival was 91% and remained excellent in all the subsets analysed. Moreover, the quality of life of these patients was good. Over the 10 year follow up, 16 (36%) of the patients treated medically and 13 (26%) in the surgical group were admitted to hospital because of cardiovascular events (including late coronary surgery in four of the patients treated medically). Lastly, 54/69 (78%) of the patients who were employed before catheterisation resumed work and 29 (42%) were still employed 10 years later. Although these data must be interpreted with care because of the limitations inherent in all retrospective studies, it appears that the long term results of conventional medical or surgical treatment are excellent in patients with single vessel coronary artery disease in whom percutaneous transluminal coronary angioplasty is now an option.     

Long-term prognosis of “variant” angina with medical treatment

One hundred thirty-eight patients with “variant angina” were followed up for periods of 2 to 8 years. All patients had a history of angina at rest, and 42 percent also had exertional angina. Normal coronary arteries were found in 9 of the 107 patients who underwent coronary arteriography; the remainder had stenosis greater than 50 percent in diameter of at least one major vessel. Coronary vasospasm was demonstrated in all 37 patients studied with coronary arteriography during angina at rest. Twenty-eight patients had acute myocardial infarction and five patients died within 1 month of admission to hospital. Of the 133 surviving patients, 120 were treated medically and 13 underwent coronary arterial surgery. In the medically treated group, only seven patients died and only four had acute myocardial infarction during the remainder of the follow-up period. Symptoms became less frequent and less severe; approximately 50 percent of the patients remained completely asymptomatic for at least 12 months by the end of the 4th year. Death, acute myocardial infarction and persistence of symptoms were more frequent in those patients with more severe coronary atherosclerotic disease although, even in this group, the overall incidence of death and acute myocardial infarction was small. It is concluded that the prognosis of patients with “variant” angina receiving appropriate medical therapy is reasonably good after the acute phase, even in the presence of severe coronary atherosclerosis.     

Ischemic cardiomyopathy: the myopathy of coronary artery disease. Natural history and results of medical versus surgical treatment

Clinical, hemodynamic and angiographic data were analyzed in 66 patients with coronary artery disease and severe generalized left ventricular dysfunction (ischemic cardiomyopathy) in order to determine their prognosis and examine the results of medical and surgical management. Seventy-six percent of patients had angina, 85 percent a history of one or more myocardial infarctions, 73 percent cardiomegaly, 38 percent mitral regurgitation, 98 percent severe stenosis of two or three major coronary arteries, and 100 percent a left ventricular ejection fraction of 25 percent or less.Forty-two patients were managed medically, and 24 surgically with aortocoronary bypass grafts or ventricular plication, or both. The clinical and hemodynamic findings in both groups were nearly identical. In a follow-up period of 12 months, the mortality rate was 31 percent in the medical group and 50 percent in the surgical group, with 83 percent of the surgical deaths occurring within 1 month of operation. There was no significant difference in the functional status of medical and surgical survivors. Regardless of therapy, patients with mitral regurgitation or a left ventricular end-diastolic pressure of 24 mm Hg or greater had a significantly higher mortality rate than patients without these findings. This study indicates that patients with ischemic cardiomyopathy have a poor prognosis, and surgical intervention with current available techniques has a high operative mortality rate without significantly altering the symptoms in the survivors.     

Bypass graft surgery versus medical therapy of angina pectoris

Forty patients with angina pectoris (New York Heart Association functional class III) despite medical therapy were studied. Twenty who underwent coronary bypass graft surgery and 20 comparable patients treated only medically underwent exercise tests during the control period and 3, 6, 9 and 12 months later. One of 20 surgically treated patients (5 percent) died at operation. One year mortality rates were 10 percent (2 of 20 surgically treated patients) and 5 percent (1 of 20 medically treated patients). Three of 20 patients (15 percent) had a myocardial infarction at operation. By 1 year, 4 of 20 surgically treated patients (20 percent) and 1 of 20 medically treated patients (5 percent) had had a myocardial infarction. At 1 year, 18 of 27 grafts (67 percent) were patent. Three and 6 months after the control period, no angina after exercise, a more than 25 percent increase in exercise performance until angina, and an increase in the value for product of systolic blood pressure times heart rate occurred in significantly more surgically than medically treated patients. One year after the control period, 14 of 18 surgically treated patients (78 percent) and 10 of 19 medically treated patients (53 percent) had no angina after exercise or a more than 25 percent increase in exercise performance until angina. One year after the control period, 4 of 16 medical patients (25 percent) and 6 of 15 surgical patients (40 percent) not receiving digitalis had no postexercise ischemic S-T segment depression. These data suggest that the coronary artery bypass operation should be considered only if medical therapy fails to relieve disabling angina.     

Unstable angina pectoris: disease picture and study of its course

The object of the present study is to analyse the history of patients with typical unstable angina. For this purpose the data of all patients admitted to the Hannover Medical School between 1977 and 1983 and taken to the CCU because of proven unstable angina (history, duration of symptoms, intrahospital mortality, incidence of infarction, medical or surgical therapy, coronary pathomorphology, mortality after release from hospital, late incidence of infarction and rehospitalization) were documented and stored on a data bank for statistical analysis. 123 patients were entered into the study (97 males, 26 females; average age 58.4 +/- 9.2 years); during hospitalization all patients had angina at rest, 94% had transient ECG-changes (ST-segment changes, BBB etc.). The average follow-up was 4.2 +/- 2.0 years. 80 patients of the whole study population were treated medically, 43 underwent early bypass surgery. The two groups were different with respect to coronary pathomorphology (number of diseased vessels) as well as left ventricular wall motion, which was significantly more impaired in the surgical group (p less than 0.05). The hospital-mortality in the surgical group amounted to 9.3% (n = 4), the incidence of infarction to 18.6% (n = 8); the hospital mortality in medically treated patients was 2.5% (n = 2), the incidence of infarction 7.5% (n = 6). During the whole study period (average follow-up 4.2 years) the overall mortality amounted to 21%, the infarction rate was 23.5%: The cumulative survival rates revealed no significant difference between the 2 groups: after 3 years 84% of all patients were still alive, 65% without new infarction during the observation period; the rate of rehospitalization amounted to 50%. At the end of the study class III or IV angina (NYHA-criteria) was much more common in the medically treated than in the surgically treated group (NYHA mean 2.5 versus 2.0; p less than 0.5). The relatively high rate of perioperative death and myocardial infarction in the surgical group is based on the selection of patients according to coronary pathomorphology and the clinical status.     

Unstable angina pectoris: A randomized study of patients treated medically and surgically

Fifty patients with the clinical syndrome of unstable angina pectoris were evaluated. Twenty-seven were randomized into medical or surgical treatment groups and subsequently followed up. The results of the study reveal that: (1) there is approximately a 16 percent incidence rate of significant left main coronary artery disease in patients with this entity at our institution; (2) 10 percent of patients do not have angiographically significant coronary artery disease; (3) pain relief is better in the surgically treated patients, but the 1 1/2 year survival rate is not significantly different between the groups; (4) 50 percent of the medically treated patients again had the syndrome of unstable angina pectoris in the initial few months of the follow-up period; (5) the operative and late postoperative mortality rate in patients presenting with unstable angina pectoris and left main coronary artery disease in this small group of patients was 43 percent; and (6) four of six patients with this syndrome whose condition was deemed inoperable and who were not randomized died within the subsequent few months.     

Ten-year follow-up of quality of life in patients randomized to receive medical therapy or coronary artery bypass graft surgery. The Coronary Artery Surgery Study (CASS)

Quality of life indexes were assessed in 780 patients 10 years after randomization to medical therapy (n = 390) or coronary artery bypass graft surgery (n = 390) in the Coronary Artery Surgery Study. At 10 years, mortality was 21.8% in the medical group and 19.2% in the surgical group (p = NS), and 144 (37%) of the medical group had undergone surgery because of increasing chest pain. At study entry, 22% of medical and surgical patients were angina free; at 1 and 5 years after entry, the frequency of asymptomatic patients was 66% and 63% in the surgical group and 30% and 38% in the medical group. However, by 10 years after entry, the proportion of patients free of angina had fallen to 47% in the surgical group and to 42% in the medical group. Activity limitation and use of beta-blockers and long-acting nitrates were less in the surgical than the medical group at 1 and 5 years after entry but little different from the medical group at 10 years after entry. Throughout follow-up, recreational status, employment status, frequency of heart failure, use of other medications, and hospitalization frequency were similar between the two groups. Thus, indexes of quality of life such as angina relief, increased activity, and reduction in use of antianginal medications initially appear superior in patients with stable manifestations of ischemic heart disease assigned to surgery, but by 10 years after entry, these advantages are much less apparent. Although the observed similarities of the medically and surgically assigned groups at 10 years reflect return of symptoms in the surgical group to some extent, a more important explanation is the performance of late surgery in a large proportion of the medically assigned patients, rendering them asymptomatic.     

Presentation,management, and follow-up evaluation of infective endocarditis in drug addicts

Records of 97 episodes of IE in parenteral drug abusers from 1965 to 1976 were examined with follow-up obtained on most patients. Thirty-two percent had tricuspid regurgitation, 29% had aortic regurgitation, 25% had mitral regurgitation, and 13% had mixed lesions. Principal organisms were Staphylococcus aureus 36%, Group D Streptococcus 19%, fungus 12%, and Serratia marcescens 8%. Only one patient with a typical clinical picture of IE had multiple negative blood cultures, 28% of patients had surgical therapy with paravalvular leaks occurring in 50% and second infections occurring in 24%. Sixty percent of these patients died; only 16% of the deaths were perioperative. Seventy-three percent of patients had medical therapy alone with a mortality rate of > 70% occurring with Serratia, fungus, or aortic valve infection; most of these infections occurred early in the hospital course. Seventeen percent of medically managed patients had second infections. Surgical management produced immediate increased survival in hemodynamically severe IE, but long-term postoperative mortality was high in these drug addicts.     

Effects of surgical versus medical treatment of long-term prognosis in angina at rest: an observational non-randomized study of 400 patients

The effect of surgical versus medical treatment on long-termprognosis in angina at rest was assessed using the Cox regressionmodel for survival analysis in 400 patients complaining of recurrentepisodes of resting chest pain associated with transient repolarizationchanges. The surgical group included 185 patients, and the medicalgroup 215. Surgically treated patients more frequently had two-and three-vessel disease, while single-vessel disease prevailedin medically treated patients (P<0·01). No differencebetween the two groups was found in mean values of left ventricularend diastolic pressure and ejection fraction. Three variableswere identified as independent predictors of prognosis in allpatients: left ventricular end-diastolic pressure (P < 0·001),age > 45 years (P < 0·05), and number of diseasedvessels (P < 0·05). Treatment modality did not resultin different long-term survival in the entire population. However,patients with three-vessel disease had a better outcome withsurgical than with medical therapy (P < 0·05). Although our conclusions must be tempered by consideration ofthe limitations of non-randomized studies, these results showthat surgical treatment may improve survival in patients withangina at rest and three-vessel disease.     

Use of percutaneous transluminal coronary angioplasty and bypass surgery despite improved medical therapy for unstable angina pectoris

To evaluate current strategies for the management of unstable angina, 104 consecutive patients admitted to the coronary care unit with unstable angina during a 6-month period were followed prospectively. Although 58 patients had symptomatic relief with the initiation of intensive medical therapy, 46 (44%) continued to have episodes of angina despite maximal tolerated triple-drug antianginal therapy as well as aspirin or heparin, or both. In-hospital mortality for the 104 patients was 4%. The incidence of myocardial infarction was 8%, and differed (p less than 0.01) for the medically responsive group (3%) vs the medically refractory group (13%). Based on clinical status and coronary anatomy, patients were referred for either bypass surgery (46%), coronary angioplasty (41%) or continued medical therapy (13%). Choice of therapy varied according to the extent of coronary disease, with coronary angioplasty attempted in 72% of patients with 1-vessel disease, 44% of patients with 2-vessel disease and 7% of patients with 3-vessel disease. Angioplasty was performed with an initial success rate of 88%, and compared favorably with bypass surgery in terms of in-hospital mortality (0 vs 11%), late mortality (2.8 vs 7.7%), freedom from angina (62 vs 69%) and subsequent employment (44 vs 27%) at 18 months follow-up. The favorable results of angioplasty in this prospective observational study suggest that additional randomized trials should be conducted in this important patient group.     

Clinical factors affecting the immediate outcome of PTCA in patients with unstable angina and poor candidates for surgery

Percutaneous Transluminal Coronary Angioplasty (PTCA) has been successfully applied in unstable angina to carefully selected patients. In this study, PTCA was performed in 277 consecutive patients suffering from unstable angina and for whom bypass surgery was not a valid alternative because either of inoperable conditions or of emergency, or because surgery was not the best option. All patients were admitted first to the intensive care unit where an attempt was made to control unstable angina under conventional medical therapy using at least iv nitroderivative, heparin, and calcium blockers. After a standardized preparation PTCA was performed either as an emergency procedure in medically refractory unstable angina (107 cases) or as an elective procedure in controlled situations after a 7 to 10 days symptom-free period. Three hundred fifty-three coronary vessels were attempted. Results of this group are compared with those of a control group made of 670 consecutive stable patients recruited during the same period, and clinical characteristics are envisaged as potential predictive factors. Unstable angina is undoubtedly associated with a higher overall complication rate, but the immediate outcome is strongly affected by the clinical context. As an example, respective success and mortality rates are: 93% and 0% when a full revascularization is attempted; 91% and 0% in elective procedures in patients under 60; 87% and 1.2% in elective PTCA for multiple vessel disease; 80% and 6.5% in emergency PTCA; 80% and 11% in the overall triple vessel disease; 84% and 16% in patients with deeply altered ejection fraction; and 58% and 26% in triple vessel disease with 2 previously occluded coronary arteries.(ABSTRACT TRUNCATED AT 250 WORDS)     

Variant Angina—Correlation of Clinical, Electrocardiographic and Angiographic Features: Results of Medical and Surgical Management

Summary Angiographic coronary artery disease (CAD) was correlated with clinical features, electrocardiographic (ECG) findings and the results of medical management or aortocoronary bypass in 42 patients with angina at rest associated with transient ST segment elevation (variant angina).
Patients were divided into three sub-sets based on the coronary arteriographic findings. On the basis of > 75% luminal diameter narrowing, 28 patients had multiple vessel, ten had single vessel and four had minimal (< 50% narrowing) CAD. The angiographic sub-sets did not differ significantly in age, sex, coronary risk factors, time from onset of rest pain to coronary angiography, or in the presence of arrhythmias during ischaemic episodes. Patients with multiple vessel CAD more commonly had prior coronary events (P < 0·01), an abnormal baseline ECG (P < 0·05) or both (P < 0·001). These features did not distinguish patients with single vessel from those with minimal CAD. ST elevation in the inferior leads during episodes of myocardial ischaemia was more common (P < 0·005) in patients with minimal CAD.
Twenty-four patients with multiple vessel and six with single vessel CAD underwent aortocoronary by-pass surgery and relief of variant angina was achieved in all 25 long-term survivors during an average follow-up period of 36 months. Twelve patients (four of each subset) were treated medically. Among those with multiple vessel CAD, the small medically treated numbers precluded valid comparison of medical and surgical results. Patients with single vessel CAD followed for an average period of 17 months compared unfavourably with the operated group. Calcium antagonists or nitrates controlled variant angina in patients with minimal CAD followed for an average of 27 months.     

Five-year effect of medical and surgical therapy on resting left ventricular function in stable angina: Veterans administration cooperative study

The effect of coronary artery bypass grafting (CABG) and medical therapy on 5-year resting left ventricular (LV) function was studied in 194 randomized patients with stable angina in the Veterans Administration Study of Coronary Artery Bypass Surgery. LV ejection fraction (EF) was determined in a central laboratory. The 92 medical and 102 surgical patients were comparable at entry with respect to historic, angiographic and electrocardiographic prognostic indicators. Twenty-eight percent of the medical and 30% of the surgical patients had a baseline EF of < 50%. There was no significant change in mean EF between baseline and 5-year values in either treatment group. The base-line and 5-year values were 56 and 58% in each treatment group. Intervening myocardial infarction (MI) had an adverse effect in medically treated patients (59 to 46%, p < 0.01) and in surgically treated patients with late Ml (58 to 47%, difference not significant). Perioperative MI was not associated with a decrease in EF (56 to 58%, difference not significant). These findings extend the similar results of previous short-term studies of the effect of coronary bypass surgery on resting LV function to 5 years, and provide data in a comparable medical control group.     

A comparison of emergency resection and staged management in perforated diverticular disease

This retrospective view examines the outcome of surgical treatment of perforated diverticular disease in one hospital in the period 1976 to 1983. Of the 78 patients, 38 underwent emergency colonic resection (group A) whereas 40 (group b) were treated by proximal colostomy and drainage (37 patients) or suture of the perforation with drainage (three patients). There was no significant difference between groups A and B in terms of operative mortality (21 percentvs. 24 percent, respectively). Mortality rates were highest in patients with generalized peritonitis treated by colostomy and drainage (36 percent), whereas those with localized disease undergoing resection had a mortality rate of 17 percent (P<.05). Eight of the 40 patients in group B developed fistulas whereas none of the group A patients had this complication. Only four (16 percent) of the surviving group A patients were left with a permanen colostomy as opposed to 15 (56 percent) of their counterparts in group B. In the presence of perforated diverticular disease, emergency resection carries a lower morbidity than colostomy and drainage, although the present review shows no statistically significant differences in terms of mortality.     

Value of coronary bypass surgery. Controversies in cardiology: Part I.

The value of coronary bypass surgery has been studied carefully during the last decade. Four methods, none perfect, have been used to compare the results of such surgery with the results of medical therapy. New data are likely to be merely supportive rather than the outcome of a definitive study with a new and a acceptable experimental design. It is therefore time to analyze the available data in light of the treacherousness of the disease and to determine if a clear trend is evident. There appears to be sufficient evidence to state that properly performed coronary bypass surgery will increase coronary blood flow and relieve angina pectoris in 90 percent of patients; total relief of angina can be expected in 60 percent and partial relief in 30 percent. Compared with modern medical therapy, properly performed coronary bypass surgery appears to prolong the life of patients who have obstruction of the left main coronary artery or triple or double vessel disease. There is not adequate evidence to state that the procedure will prolong the life of patients with single vessel obstruction. However, patients with single vessel obstruction and unacceptable angina pectoris should be considered for bypass surgery (especially patients with obstruction of the left anterior descending coronary artery). In practice, at Emory University Hospital, Atlanta, bypass surgery is recommended for young people with few symptoms if compelling obstructing lesions are present and in older patients only if their symptoms require it. Medical therapy is given before and after bypass surgery. When bypass surgery is performed in an excellent fashion (operative risk 1 percent) a great deal of "controversy" about this problem vanishes.