To identify predictors of mortality in medically treated patients with symptomatic coronary artery disease, 30 variables were analyzed in 4,083 patients. Regression analysis demonstrated that seven variables were independent predictors of survival. A high risk subgroup (annual mortality rate above 5%) was identified, consisting of patients with either a congestive heart failure score of 3 to 4 or 1 mm or greater ST segment depression and final exercise stage of 1 or less. When all 30 variables were analyzed conjointly, the left ventricular contraction pattern (p less than 0.0001) and the number of diseased coronary vessels (p less than 0.003) proved to be the most important predictors of survival. In a subgroup of 572 patients with three vessel coronary disease and preserved left ventricular function, the probability of survival at 4 years ranged from 53% for patients only able to achieve stage 1/2 of exercise to 100% for patients able to exercise into stage 5 (p less than 0.004). Thus, in patients with defined coronary pathoanatomy, clinical and exercise variables primarily relating to the functional state of the left ventricle are helpful in assessing prognosis.

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%7s and 381% 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 f3-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.

The onset of bundle branch block during acute myocardial infarction is indicative of ischemia in the distribution of the left anterior descending coronary artery. However, whether patients with chronic coronary artery disease and bundle branch block have a predominance of left anterior descending artery lesions is not known. Similarly, the prognostic implications of bundle branch block have been studied primarily in the setting of acute myocardial infarction, and the independent prognostic implications of bundle branch block in patients with chronic coronary artery disease are not known. The electrocardiograms (ECGs) of 15,609 patients with chronic coronary artery disease who underwent coronary and left ventricular angiography as part of the Coronary Artery Surgery Study (CASS) were reviewed, and 522 patients with bundle branch block were identified. Patients with bundle branch block had both more extensive coronary artery disease and worse left ventricular function than did patients without bundle branch block. However, no particular location of coronary artery stenosis or left ventricular wall motion abnormality predominated in patients with bundle branch block. During a follow-up period of 4.9 +/- 1.3 years, 2,386 patients died. Actuarial probability of mortality at 2 years in patients with left bundle branch block was more than five times that in patients without bundle branch block (p less than 0.0001), and in patients with right bundle branch block the mortality rate was approximately twice that in patients without bundle branch block (p less than 0.0001). Stepwise Cox regression analysis showed that left bundle branch block, but not right bundle branch block, was a strong predictor of mortality, independent of degree of heart failure, extent of coronary disease and other variables (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Modest benefits in quality of life for > or = 1 year occurred when patients with left ventricular dysfunction and symptomatic heart failure were treated with enalapril. No apparent beneficial or adverse effect on quality of life was observed with enalapril in asymptomatic patients with left ventricular dysfunction.