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European Journal of Cardio-Thoracic Surgery, Vol 5, 447-457, Copyright © 1991 by European Association for Cardio-thoracic Surgery
P Sergeant, E Lesaffre, W Flameng, R Suy and E Blackstone
Although survival after coronary artery bypass grafting (CABG) is the most
serious outcome information, the quality of life in living patients is
largely determined by the freedom from ischemic events. The return of
angina, acute myocardial infarct and sudden death were studied in a large
(n = 5880) population of patients undergoing CABG between 1971 and 1987.
The freedom from angina pectoris was 95%, 83% and 63% at 1, 5 and 10 years,
respectively, after surgery. Early return of angina was related to both
procedure incremental risk factors (incomplete revascularization and
non-use of the internal mammary (thoracic) artery (IMA) as a conduit) and
patient incremental risk factors (aggressiveness of the atherosclerotic
process and severity of preCABG symptoms). Late angina return was related
to patient risk factors including coexisting factors (hyperlipidemia and
hypertension), preCABG symptom severity and gender (female). The freedom
from an acute fatal or non-fatal postCABG myocardial infarct was 99%, 96%
and 85% at 1, 5 and 10 years after surgery. The incremental risk factors
for early infarction were related to incomplete revascularization, but late
infarction was related to lipid levels, coexisting diseases (diabetes,
positive family history) and non-use of IMA to LAD. The freedom from sudden
death was 99.8%, 99% and 97% at 1, 5 and 10 years, respectively, after
surgery. The incremental risk factors were dominated by the severity of the
left ventricular dysfunction. The freedom from any ischemic event (any of
the previous three) was 93%, 79% and 54% at 1, 5 and 10 years,
respectively, after surgery. The incremental risk factors included all
those cited above for the specific components. Patient- specific
predictions validate the influences of these risk factors. They demonstrate
that unlike the profound influence of the use of the IMA on survival, there
is little benefit of the use of the IMA on return of ischemic events over
and above the effect of revascularization per se. The study demonstrates
that most patients will experience return of ischemic symptoms within a
period of 15-20 years after surgery, but that this is most likely to be
return of angina and rarely sudden death.
ARTICLES
The return of clinically evident ischemia after coronary artery bypass grafting
Department of Cardiac Surgery, Gasthuisberg University Hospital, Leuven, Belgium.
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