In a randomized trial, coronary artery bypass grafting — compared with good medical therapy — did not lower mortality at 5 years.
Does coronary artery bypass grafting (CABG) lower medium-term mortality in patients with substantially reduced left ventricular ejection fraction (LVEF) and coronary artery disease suitable for CABG? To answer this question, researchers randomized 1200 patients with coronary disease and LVEF 35% either to optimal medical therapy alone or medical therapy plus CABG. Most patients had two- or three-vessel disease; patients with left main stenosis and severe angina were excluded. During the trial, 17% of medical-therapy patients crossed over to CABG.
After average follow-up of almost 5 years, all-cause mortality (the primary outcome) was similar in the CABG and medical therapy groups (36% and 41%; P=0.12). Early mortality was higher in the CABG group than in the medical-therapy group, owing to perioperative death (4% vs. 1% at 30 days); after 2 or 3 years, the death rate was slightly lower in the CABG group. Several secondary endpoints (combinations of mortality and hospitalization or additional coronary revascularization) favored the CABG group. Interestingly, assessment of myocardial viability (using noninvasive imaging) did not predict which patients would benefit from CABG.
Comment: In this study of patients with LVEF 35% and coronary artery disease, but without left main disease, who received aggressive medical management, addition of CABG conferred no significant mortality benefit. Medical management of such patients is appropriate unless coronary revascularization is required for other reasons, such as uncontrolled angina.
Source: Journal Watch General Medicine