Comparison of medicine alone, coronary angioplasty, and left internal mammary artery-coronary artery bypass for one-vessel proximal left anterior descending coronary artery disease

Despite the deleterious and sometimes catastrophic consequences of proximal left anterior descending (LAD) artery occlusian, there is a paucity of dat a to guide the treatment of patients with such disease. Our aim was to desc ribe outcomes with medical therapy, angioplasty, or left internal mammary a rtery (LIMA) bypass grafting in patients with 1-vessel, proximal LAD diseas e. We retrospectively analyzed prospectively collected data from 1,188 pati ents first presenting only with proximal LAD disease at 1 center over 9 yea rs. We assessed the rates of death, acute myocardial infarctian, and repeat intervention by initial treatment over a median 5.7 years of follow-vp. Pa tients undergoing angioplasty or LIMA bypass were more often men and had pr ogressive or unstable angina; those receiving medical therapy had a lower m edian ejection fraction. Both revascularization procedures offered slightly better adjusted survival versus medicine (hazard ratio for angioplasty, 0. 82; 95% confidence interval, 0.60 to 1.11; hazard ratio for bypass, 0.74; 9 5% confidence interval, 0.44 to 1.23). Bypass, but nat angioplasty, was ass ociated with significantly fewer composite end point events (death, infarct ion, or reintervention, p <0.0001), and angioplasty was associated with a h igher composite event rate than bypass or medical therapy (p <0.0001 and p = 0.0003, respectively). The initial advantages of bypass and medicine over angioplasty diminished over time; angioplasty became more advantageous tha n medicine after 1 year (p = 0.05) and not significantly different from byp ass. Treatment of 1-vessel, proximal LAD disease with medicine, angioplasty , or LIMA bypass resulted in comparable adjusted survival. However, LIMA by pass alone reduced the long-term incidence of infarctions and repeat proced ures. (C) 2000 by Excerpta Medica, Inc.