Heart failure: CABG was beneficial in patients with angina.

Clinical bottom line (level 2a)

  1. Patients with moderate to severe left ventricular systolic dysfunction and concomitant limiting angina had improved survival and physical functioning allowing CABG.
  2. The benefits of revascularisation in patients with heart failure and no angina were unclear.
  3. The role of angioplasty as an alternative to CABG in patients with heart failure was unclear.
Baker et al: Journal of the American Medical Association 1994; 272 (19): 1528-1534
Expires July 2003

The study

Systematic review of all studies of
  • Patients: moderate to severe left ventricular dysfunction (ejection <40%)
  • Intervention: coronary artery bypass grafting (CABG) or percutaneous coronary angioplasty
  • Outcome: 1. operative mortality, total mortality, change in functional status (changes in ejection fraction, change in NYHA class, and symptom improvement), risk of procedure-related complications;2. relief of angina, improvement in ventricular function, risk of procedure-related complications


    • Articles found in ? using MEDLINE and EMBASE, 1966 to 1993 (search terms: detailed in text ) and review of references in relevant articles

    Selection criteria: as above
    Appraisal criteria: using set criteria
    Articles excluded if: aneurysm resection, simultaneous repair of valvular congenital heart disease, mechanical assist devices, technical reviews of surgical techniques

    eight cohort studies of CABG versus medical treatment found- a total of 1264 patients undergoing CABG and 1431 receiving medical treatment. 31 case studies of CABG; 12 case studies of angioplasty. In the seven survival studies: 87% to 93% male; all patients had angina. In the 17 studies addressing function status: 81% to 100% male; most patients had angina
  • Studies were combined narratively because of significant heterogeneity between surgical techniques, study populations and study quality.

    • The evidence

    • CABG: heart failure with angina: - reduction in mortality 30% to 50%. Improvement in functional outcome, assessed as either improvement in ejection fraction or decrease in NYHA class
    • operative mortality: 5% in patients <60 with mild heart failure; 30% in patients >70 with severe heart failure and comorbid condition
    • Not enough evidence to indicate whether functional status or survival improves in the absence of angina.
    • Angioplasty: no controlled studies available. Case series suggest angioplasty can relieve angina and improve ventricular function or wall motion. Procedural complications are common- 7% in one series and mortality 3%.

    Comments

    1. The conclusions regarding CABG are based on cohort studies and case series in which the large majority (>80%) of participants are male- their conclusions may not apply equally to women.
    2. The conclusions favouring surgery in terms of improved survival are based on the three highest quality papers. However, the authors themselves point out that one of these studies shows no significant difference between medical and surgical treatment, while the results of another of these studies may be compromised by the possibility of unadjusted baseline differences between the surgical and medical treatment groups. The likely reduction in mortality therefore, may differ from the 30-50% reported.

    Citation

    1. Baker DW, Jones R, Hodges J, et al: Management of heart failure III: the role of revascularization in the treatment of patients with moderate or severe left ventricular function systolic dysfunction. Journal of the American Medical Association 1994; 272 (19): 1528-1534
    Search Terms: congestive near (heart or cardiac) in Cochrane
    Contributor: Chris Ball and Clare Wotton, July 2000
    Reviewer:

    Clinical Question.
    Patient left ventricular dysfunction
    Intervention or Exposure revascularisation
    Outcome mortality