Twelve-Year Follow-up of Survival in the Randomized European Coronary Surgery Study

Abstract

We studied survival rates among 767 men with good left ventricular function who participated in the European Coronary Surgery Study, 10 to 12 years after they were randomly assigned to either early coronary bypass surgery or medical therapy. At the projected five-year follow-up interval, we observed a significantly higher survival rate (+/- 95 percent confidence interval) in the group that was assigned to surgical treatment than in the group assigned to medical treatment (92.4 +/- 2.7 vs. 83.1 +/- 3.9 percent; P = 0.0001). During the subsequent seven years, the percentage of patients who survived decreased more rapidly in the surgically treated than in the medically treated group (70.6 +/- 5.8 vs. 66.7 +/- 5.3 percent at 12 years). Thus, the improvement in the survival rate among patients with stable angina who were treated surgically appears to have been attenuated after five years. However, the gradually diminishing difference between the two survival curves still favored surgical treatment after 12 years (P = 0.04), despite the fact that 136 patients in the medically treated group had coronary bypass surgery and 23 in the "surgically treated" group did not. The benefit of surgical treatment tended to be greater, but not significantly so, as assessed by interaction analysis in the subgroups of patients who were older or who had signs of ischemia or previous infarction on the resting electrocardiogram, a markedly ischemic response to exercise testing, peripheral arterial disease, an absence of hypertension, and proximal obstruction in the left anterior descending artery. The reasons for the loss of a beneficial effect of surgery after five years are unknown and merit further study.

Trials and tribulations associated with angina and traditional therapeutic approaches

“…23 Following these sub-analyses, the subgroup with p-LAD involvement (> = 50% stenosis) and presence of 2-vessel or 3-vessel CAD was evaluated. 19 This analysis revealed that CABGS, compared to medical therapy, was associated with a significantly lower mortality rate. On the basis of this subanalysis, 19 patients with p-LAD involvement were identified as a high-risk subgroup that appeared to derive benefit from therapy with CABGS.…”

“…The VACSS 12,13 included patients with left main coronary (LMC) artery involvement; LMC + (abnormal left ventricular function (LVF) or normal LVF); no-LMC, 2v + abnormal LVF; 3v + abnormal LVF; 1v, 2v, 3v, impaired LVF, nonimpaired LVF; high angiographic risk (3v + impaired LVF); and low angiographic risk ( Using an intention to treat (ITT) analysis approach the VACSS, ECSS, and CASS trials revealed similar mortality rates between the main CABGS and medical therapy arms. 14,19,26,27 The ECSS is the only trial that showed on long-term follow-up a small, but statistically significant, improvement in mortality rate with CABGS. 19 The rates of fatal and nonfatal MI) in these trials were similar between the patients who underwent CABGS, compared to patient who did not undergo CABGS.…”

“…14,19,26,27 The ECSS is the only trial that showed on long-term follow-up a small, but statistically significant, improvement in mortality rate with CABGS. 19 The rates of fatal and nonfatal MI) in these trials were similar between the patients who underwent CABGS, compared to patient who did not undergo CABGS. 17,23,25 The VACSS is the only trial that reported a small, but statistically significant, increase in the incidence of nonfatal MI among patients who underwent CABGS.…”

“…Interestingly, in the ECSS trial, the post hoc analysis of the LMC subgroup revealed no difference in mortality between the CABGS and no-CABGS arms. 19 In an ensuing report, the VACSS evaluated another subgroup without LMC involvement. This was the angiographic-high risk subgroup (3-vessel CAD + impaired LV function).…”

“…18,20 -22 However, in the subgroup with 3-vessel CAD there was a statistically significant difference in survival favoring the CABGS group. 19 Further analysis of the 2-vessel CAD subgroup was carried out into those with involvement (>=50% stenosis) of the proximal-LAD (p-LAD) and those without involvement (<50% stenosis) of the p-LAD. 21 This analysis revealed that in patients with 2-vessel CAD + p-LAD involvement CABGS, compared to medical therapy, was associated with a relatively small, but statistically significant, improved survival.…”