MANAGEMENT OF HEART-FAILURE .3. THE ROLE OF REVASCULARIZATION IN THE TREATMENT OF PATIENTS WITH MODERATE OR SEVERE LEFT-VENTRICULAR SYSTOLIC DYSFUNCTION
Dw. Baker et al., MANAGEMENT OF HEART-FAILURE .3. THE ROLE OF REVASCULARIZATION IN THE TREATMENT OF PATIENTS WITH MODERATE OR SEVERE LEFT-VENTRICULAR SYSTOLIC DYSFUNCTION, JAMA, the journal of the American Medical Association, 272(19), 1994, pp. 1528-1534
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.