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PubMed1990

Two-year outcome after angiographically documented myocardial reperfusion for acute coronary occlusion. Thrombolysis and Angioplasty Study Group.

Reperfusion therapy has been clearly shown to decrease the early mortality after acute myocardial infarction, but the impact of this therapy on long-term survival has been less extensively evaluated. This study reports the extended follow-up of a large cohort of 810 patients treated with intravenous thrombolytic therapy combined, when considered necessary to maintain or augment infarct vessel patency, with mechanical reperfusion therapies. Each patient underwent coronary angiography within 2 hours of the initiation of the thrombolytic infusion. Coronary angioplasty was performed in 62% of the patients before hospital discharge and 21% underwent coronary artery bypass graft surgery. Follow-up was obtained in 96% to a mean of 18.8 months (range, 1.5 to 48 months). All-cause mortality over this period was 3.3%; 2.1% died from cardiac causes. Nonfatal reinfarction occurred in 5.1%. Although the low event rate limits the validity of statistical comparisons, the patients who survived the follow-up period tended to be younger (56 +/- 10 vs 65 +/- 7 years), to have better predischarge left ventricular function (left ventricular ejection fraction, 52 +/- 11 vs 46 +/- 13%) and to have a lower prevalence of multivessel coronary artery disease (45 vs 67%). This excellent long-term survival may, in part, reflect the exclusion of high-risk patients from enrollment in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) studies. It may also be attributable, however, to the frequent use of combined thrombolysis and mechanical revascularization in this population.

Angioplasty, Balloon, Coronary↗
PubMed1993

Determinants of survival and recovery of left ventricular function after aortic valve replacement.

To determine factors that influence survival and recovery of ventricular function in patients undergoing aortic valve replacement in the current surgical era, baseline risk factors related to outcome were analyzed in 1,012 consecutive patients undergoing aortic valve replacement between 1983 and 1990. Forty-two percent of patients underwent concomitant coronary bypass. Observed survival probabilities (expressed as 30-day/5-year) were 0.97/0.81 overall, 0.99/0.89 for patients aged less than 70 years, and 0.95/0.74 for patients aged 70 years or greater. Advanced age (p < 0.0001), decreased ejection fraction (p < 0.0001), extent of coronary disease (p < 0.006), smaller prosthetic valve (p < 0.03), and advanced New York Heart Association class (p < 0.04) were incremental risk factors for mortality. In patients with preoperative ventricular dysfunction (ejection fraction < or = 0.45), ejection fraction measured 1.4 years after aortic valve replacement improved in 72% and the mean increment in ejection fraction was 0.175 (95% confidence interval, 0.154 to 0.195). The increment in ejection fraction was greater in female patients than in male patients (p < 0.02) and greater in patients without than with coronary disease (p < 0.02). Female sex (p < 0.02) and lesser extent of coronary disease (p < 0.05) were independent predictors of change in ejection fraction. In all patients, early improvement in ejection fraction conveyed an independent subsequent survival benefit (p < 0.0001). The results of aortic valve replacement in the current era are excellent, and the majority of patients with ventricular dysfunction demonstrate significant improvement. Early improvement in ejection fraction, influenced by coexistent coronary artery disease and sex-associated factors, importantly affects subsequent survival.

Aged↗
PubMed1991

Current risk of coronary bypass for unstable angina.

The risk associated with surgical revascularization for unstable angina is critically dependent upon the clinical presentation of the patient. For this study, between January 1982 and December 1987, clinical, angiographic, operative and hospital outcome data were collected prospectively for 6539 patients undergoing surgery for unstable angina. Urgent surgery was performed in 1523 patients (23.3%), while 5016 (76.7%) underwent semielective revascularization. The mean age was 58.9 +/- 9.2 years and 805 patients (12.3%) were aged 70 years or above. The male:female ratio was 3.6:1. Depressed left ventricular function (left ventricular ejection fraction less than 40%) was present in 27.2% of the population. Preoperative myocardial infarction (within 30 days of surgery) had occurred in 588 patients (9.0%). Operative mortality was 4.6% (301 deaths). Stepwise logistic regression analysis was performed to determine the independent predictors of operative mortality. The following variables were selected in descending order: urgent surgery (P less than 0.001), coronary reoperation (P less than 0.001), depressed left ventricular (P less than 0.001), female gender (P less than 0.001), increasing age (P less than 0.001), left main stenosis (P = 0.002), and preoperative myocardial infarction (P less than 0.001). Predicted operative mortality varied between 0.5 +/- 0.3% and 82.6 +/- 12.7%. The most important determinant for patients with a preoperative myocardial infarction was left ventricular dysfunction, whereas urgent surgery for unstable angina was the most important risk variable in those without preoperative necrosis.

Adult↗