MANAGEMENT OF HEART-FAILURE .3. THE ROLE OF REVASCULARIZATION IN THE TREATMENT OF PATIENTS WITH MODERATE OR SEVERE LEFT-VENTRICULAR SYSTOLIC DYSFUNCTION

Objective.-This article reviews the benefits and risks of coronary art ery bypass grafting and angioplasty for patients with moderate or seve re left ventricular systolic dysfunction and summarizes the recommenda tions of the expert panel for the Agency for Health Care Policy and Re search Heart Failure Guideline. Data Sources.-Data were obtained from studies published in English and referenced in MEDLINE or EMBASE betwe en 1966 and 1993. We used the search terms heart failure, congestive, congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass gr afting and angioplasty. Study Selection.-All cohort studies and case s eries that provided separate outcomes data on a subgroup of patients w ith a left ventricular ejection fraction less than 0.40 were reviewed. Data Extraction and Synthesis.-Studies were reviewed for inclusion an d exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of s tudy quality using a defined list of study flaws. Conclusion.-Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart As sociation class in patients with moderate to severe left ventricular d ysfunction and limiting angina. However, the operative mortality range s from 5% to 30% depending on patients' ejection fractions and comorbi dity. It is not clear whether patients whose predominant symptom is he art failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outco mes after angioplasty have not been adequately studied to determine th e relative risks and benefits compared with bypass grafting.