European Coronary Surgery Study Group - ECSS

Description:

CABG vs. medical therapy for mortality in unstable angina.

Hypothesis:

Surgery provides survival benefits for men with angina pectoris.

Study Design

Study Design:

Patients Screened: Not given
Patients Enrolled: 768
Mean Follow Up: 5 years in formal study; 10-12 years in separate follow-up
Mean Patient Age: 49.9 years
Female: 0
Mean Ejection Fraction: 64.6%

Patient Populations:

Men aged <65 Angina pectoris > 50% obstruction in two or more major vessels

Exclusions:

Left ventricular ejection fraction of < 0.5

Primary Endpoints:

Total mortality

Secondary Endpoints:

β-blockers used
Revascularization and graft patency
Angina pectoris
Exercise performance

Drug/Procedures Used:

Best practice in each center, based on clinical judgment: CABG or medical therapy.

Concomitant Medications:

β-blockers (74% of medical group, 75% of surgical group at entry)
Nitrates (78% of medical group, 82% of surgical group at entry)
Digitalis (9% of medical group, 13% of surgical group)
Diuretics (11% of medical group, 10% of surgical group)

Principal Findings:

At 5 years:
Survival was improved significantly by surgery in the total population (92.4±2.7% vs 83.1±3.9%, p = 0.0001), in patients with 3-vessel disease, and in patients with stenosis in the proximal third of the left anterior descending artery constituting a component of either 2-or 3-vessel disease.

The surgically-treated group did significantly better than the medical group in terms of angina attacks, use of β-blockers and nitrates, and exercise performance, but the difference between the 2 treatments tended to decrease with time.

At 10 to 12 years:
In the ensuing 7 years, the percentage of patients who survived decreased more rapidly in the surgically-treated group than in the medically-treated group (70.6±5.8% vs 66.7±5.3% at 12 years).

The gradually-diminishing difference between the two survival curves still favors surgical treatment after 12 years (p = 0.04).

Interpretation:

Surgery offers survival benefits for at least 5 years, and beyond that, for selected patients. The fact that surgery does not prevent the formation of new lesions may account for the diminishing difference in survival rates beyond 5 years. However, revascularization should not be delayed in patients who have risk factors, refractory angina, or both despite adequate medical treatment and measures aimed at secondary prevention.

References:

1. Lancet 1979;8122:889-93. 2-year survival
2. Lancet 1980;8193:491-5. 3-year followup
3. Lancet 1982;8309:1173-82. Final results (5-8 year follow-up)
4. N Engl J Med 1988;319:332-7. 12-year followup

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias

Keywords: Secondary Prevention, Survival Rate, Nitrates, Coronary Disease, Risk Factors, Constriction, Pathologic, Coronary Artery Bypass


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