0
April 14, 1989, Vol 261, No. 14 >
ARTICLE | April 14, 1989

The Evolution of Medical and Surgical Therapy for Coronary Artery Disease: Title and subTitle BreakA 15-Year Perspective FREE

Robert M. Califf, MD; Frank E. Harrell, Jr, PhD; Kerry L. Lee, PhD; J. Scott Rankin, MD; Mark A. Hlatky, MD; Daniel B. Mark, MD, MPH; Robert H. Jones, MD; Lawrence H. Muhlbaier, PhD; H. Newland Oldham, Jr, MD; David B. Pryor, MD
[+] Author Affiliations

Reprint requests to Duke University Medical Center, Box 31123, Durham, NC 27710 (Dr Califf).


JAMA. 1989;261(14):2077-2086. doi:10.1001/jama.1989.03420140079032
Text Size: A A A
Published online
Article
References

To elucidate the factors associated with improved survival following coronary artery bypass surgery, we studied 5809 patients receiving medical or surgical therapy for coronary artery disease. Three factors were associated with a significant surgical survival benefit: more severe coronary disease, a worse prognosis with medical therapy, and a more recent operative date. Patients with more extensive coronary obstruction had the greatest improvement in survival. Patients with a poor prognosis because of factors such as older age, severe angina, or left ventricular dysfunction had a reduction in risk that was proportionate to their overall risk on medical therapy. Survival with surgery progressively improved over the study period and by 1984 surgery was significantly better than medical therapy for most patient subgroups. Thus, contemporary coronary revascularization is associated with improved longevity in many patients with ischemic heart disease, especially in those with adverse prognostic indicators.

(JAMA. 1989;261:2077-2086)

REFERENCES

1 +
Murphy ML, Hultgren HN, Detre K, Thomsen J, Takaro T, and participants of the Veterans Administration Cooperative Study.  Treatment of chronic stable angina: a preliminary report of survival data . N Engl J Med. 1977;;297:621-627.
2 +
Unstable Angina Pectoris Study Group.  Unstable angina pectoris national cooperative study group to compare medical and surgical therapy, II: in-hospital experience and initial follow-up results in patients with one, two and three vessel disease . Am J Cardiol. 1978;;42:839-848.
3 +
Varnauskas E and the European Coronary Surgery Study Group.  Twelve-year follow-up of survival in the randomized European Coronary Surgery Study . N Engl J Med. 1988;;319:332-337.
4 +
Coronary Artery Surgery Study (CASS) principal investigators and associates:  A randomized trial of coronary artery bypass surgery: survival data . Circulation . 1983;;68:939-950.
5 +
Takaro T, Hultgren HN, Lipton MJ, Detre KM, and participants in the study group.  The VA cooperative randomized study of surgery for coronary arterial occlusive disease, II: subgroup with significant left main lesion . Circulation . 1976;;54( (suppl 3) ):III-107—III-117.
6 +
Killip T, Passamani E, Davis K, CASS principal investigators and associates.  Coronary artery surgery study (CASS): a randomized trial of coronary bypass surgery: eight years follow-up and survival in patients with reduced ejection fraction . Circulation . 1985;;72( (suppl 5) ):V-102—V-109.
7 +
Bonow RO, Epstein SE.  Indications for coronary artery bypass surgery in patients with chronic angina pectoris: implications of the multicenter randomized trials . Circulation . 1985;;72( (suppl 2) ):II-23—II-30.
8 +
Rahimtoola SH.  A perspective on the three large multicenter randomized clinical trials of coronary bypass surgery for chronic stable angina . Circulation . 1985;;72( (suppl 2) ):II-123—II-125.
9 +
Killip T, Ryan TJ.  Randomized trials in coronary bypass surgery . Circulation . 1985;;71:418-421.
10 +
Graboys TB, Headley A, Lown B, Lampert S, Blatt CM.  Results of a second-opinion program for coronary artery bypass graft surgery . JAMA . 1987;;258:1611-1614.
11 +
Winslow CM, Kosecoff JB, Chassin M, Kanouse D, Brook RH.  The appropriateness of performing coronary artery bypass surgery . JAMA . 1988;;260:505-509.
12 +
Coronary Artery Surgery Study (CASS) Investigators.  Comparison of coronary artery bypass surgery and medical therapy in patients 65 years of age or older . N Engl J Med. 1985;;313:217-224.
13 +
Alderman EL, Fisher LD, Litwin P, et al.  Results of coronary artery surgery in patients with poor left ventricular function . Circulation . 1983;; 68:785-795.
14 +
Kirklin JW, Blackstone EH, Rogers WJ.  The plights of the invasive treatment of ischemic heart disease . J Am Coll Cardiol. 1985;;5:158-167.
15 +
Pigott JD, Kouchoukos NT, Oberman A, Cutler GR.  Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function . J Am Coll Cardiol. 1985;;5:1036-1045.
16 +
Kaiser GC, Davis KB, Fisher LD, et al.  Survival following coronary artery bypass grafting in patients with severe angina pectoris: an observational study . J Thome Cardiovasc Surg. 1985;;89:513-524.
17 +
Harris PJ, Harrell FE Jr, Lee KL, Behar VS, Rosati RA.  Survival in medically treated coronary artery disease . Circulation . 1979;;60:1259-1269.
18 +
Harrell FE Jr, Lee KL, Califf RM, Pryor DB, Rosati RA.  Regression modelling strategies for improved prognostic prediction . Stat Med. 1984;; 3:143-152.
19 +
Pryor DB, Harrell FE Jr, Lee KL, Califf RM, Rosati RA.  An improving prognosis over time in medically treated patients with coronary heart disease . Am J Cardiol. 1983;;52:444-448.
20 +
Califf RM, McKinnis RA, Burks JA, et al.  Prognostic implications of ventricular arrhythmias during 24 hour ambulatory monitoring in patients undergoing cardiac catheterization for coronary artery disease . Am J Cardiol. 1982;;50:23-31.
21 +
Califf RM, Conley MJ, Behar VS, et al.  'Left main equivalent' coronary artery disease: its clinical presentation and prognostic significance with nonsurgical therapy . Am J Cardiol. 1984;;53:1489-1495.
22 +
Trask N, Califf RM, Conley MJ, et al.  Accuracy and interobserver variability of coronary cineangiography: a comparison with postmortem evaluation . J Am Coll Cardiol. 1984;;3:1145-1154.
23 +
Rankin JS, Sabiston DC Jr.  Physiologic determinants of the coronary blood flow, cardiac metabolism and intraoperative myocardial protection . In: Sabiston DC Jr, ed. A Textbook of Surgery . 13th ed. Philadelphia, Pa: WB Saunders; 1986;:2281.
24 +
Rankin JS, Newman GE, Bashore TM, et al.  Clinical and angiographic assessment of complex mammary artery bypass grafting . J Thorac Cardiovasc Surg. 1986;;92:832-846.
25 +
Rankin JS, Newman GE, Muhlbaier LH, Behar VS, Fedor JM, Sabiston DC Jr.  The effects of coronary revascularization on left ventricular function in ischemic heart disease . J Thorac Cardiovasc Surg. 1985;;90:818-832.
26 +
Kaplan EL, Meier P.  Nonparametric estimation from incomplete observations . J Am Stat Assoc. 1958;;53:457-481.
27 +
Chaitman BR, Davis K, Fisher LD, et al.  A life table and Cox regression analysis of patients with combined proximal left anterior descending and proximal left circumflex coronary artery disease: non—left main equivalent lesions (CASS) . Circulation . 1983;;68:1163-1170.
28 +
Cox DR.  Regression models and life-tables (with discussion) . J R Stat Soc. 1972;;34(series B): 187-220.
29 +
Breslow N.  Covariance analysis of censored survival data . Biometrics . 1974;;30:89-99.
30 +
Harrell FE Jr.  The PHGLM procedure . In: SUGI Supplemental Library User's Guide: Version 5 Edition . Cary, NC: SAS Institute Inc; 1986;:437-466.
31 +
Pryor DB, Harrell FE Jr, Rankin JS, et al.  Trends in the presentation, management and survival of patients with coronary artery disease: the Duke Data Base for Cardiovascular Disease . In: Higgins MW, Luepker RV, eds. Trends in Coronary Heart Disease Mortality: Influence of Medical Care . New York, NY: Oxford University Press Inc; 1988;:76-87.
32 +
Pryor DB, Harrell FE Jr, Rankin JS, et al.  The changing survival benefits of coronary revascularization over time . Circulation . 1987;;76( (suppl 2) ):II-13-II-21.
33 +
Laupacis A, Sackett DL, Roberts RS.  An assessment of clinically useful measures of the consequences of treatment . N Engl J Med. 1988;;318: 1728-1733.
34 +
Rankin JS, Newton JR Jr, Califf RM, et al.  Clinical characteristics and current management of medically refractory unstable angina . Ann Surg. 1984;;200:457-464.
35 +
Califf RM, Hlatky MA, Mark DB, et al.  Randomized trials of coronary artery bypass surgery: impact on clinical practice at Duke University Medical Center . Circulation . 1985;;72( (suppl 2) ):II-136— II-143.
36 +
Whalen RE, Harrell FE Jr, Lee KL, Rosati RA.  Survival of coronary artery disease patients with stable pain and normal left ventricular function treated medically or surgically at Duke University . Circulation . 1982;;65( (suppl 2) ):II-49—II-52.
37 +
Hlatky MA, Califf RM, Harrell FE Jr, Lee KL, Mark DB, Pryor DB.  Comparison of predictions based on observational data with the results of randomized controlled clinical trials of coronary artery bypass surgery . J Am Coll Cardiol. 1988;; 11:237-245.
38 +
Loop FD, Lytle BW, Cosgrove DM, et al.  Influence of the internal mammary artery on 10-year survival and other cardiac events . N Engl J Med. 1986;;314:1-9.
39 +
Califf RM, Pryor DB, Greenfield JC.  Beyond randomized clinical trials: applying clinical experience in the treatment of patients with coronary artery disease . Circulation . 1986;;74:1191-1194.
40 +
Mantel N.  Cautions on the use of medical databases . Stat Med. 1983;;2:355-362.
41 +
Byar DP.  Why databases should not replace randomized clinical trials . Biometrics . 1980;;36:337-342.
42 +
Yusuf S, Witter J, Bailey K, Furberg C.  Digitalis—a new controversy regarding an old drug: the pitfalls of inappropriate methods . Circulation . 1986;;73:14-18.
43 +
Lee KL, McNeer JF, Starmer CF, Harris PJ, Rosati RA.  Clinical judgment and statistics: lessons from a simulated randomized trial in coronary artery disease . Circulation . 1980;;61:508-515.
44 +
Hlatky MA, Lee KL, Harrell FE Jr, et al.  Tying clinical research to patient care by use of an observational database . Stat Med. 1984;;3:375-384.
45 +
Hammermeister KE, DeRouen TA, Dodge HT.  Comparison of survival of medically and surgically treated coronary disease patients in Seattle Heart Watch: a nonrandomized study . Circulation . 1982;;65( (suppl 2) ):II-53—II-59.
46 +
Ringqvist I, Fisher LD, Mock M, et al.  Prognostic value of angiographic indices of coronary artery disease from the Coronary Artery Surgery Study (CASS) . J Clin Invest. 1983;;71:1854-1866.
47 +
Harrell FE Jr, Pollack BG, Lee KL.  Graphical methods for the analysis of survival data . In: Proceedings of the Twelfth Annual SAS User's Group International Conference . Cary, NC: SAS Institute Inc; 1987;:1107-1115.
48 +
Mantel N.  Evaluation of survival data and two new rank order statistics arising in its consideration . Cancer Chemother Rep. 1966;;50:163-170.
49 +
Miller RG. Survival Analysis . New York, NY: John Wiley & Sons Inc; 1980;.
50 +
Tibshirani R.  A plain man's guide to the proportional hazards model . Clin Invest Med. 1982;; 5:63-68.
51 +
Lee KL, Harrell FE Jr, Tolley HD, Rosati RA.  A comparison of test statistics for assessing the effects of concomitant variables in survival analysis . Biometrics . 1983;;39:341-350.
52 +
Kalbfleisch JD, Prentice RL. The Statistical Analysis of Failure-Time Data . New York, NY: John Wiley & Sons Inc; 1980;.
53 +
Makuch RW.  Adjusted survival curve estimation using covariates . J Chronic Dis. 1982;;35:437-443.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Murphy ML, Hultgren HN, Detre K, Thomsen J, Takaro T, and participants of the Veterans Administration Cooperative Study.  Treatment of chronic stable angina: a preliminary report of survival data . N Engl J Med. 1977;;297:621-627.
2 +
Unstable Angina Pectoris Study Group.  Unstable angina pectoris national cooperative study group to compare medical and surgical therapy, II: in-hospital experience and initial follow-up results in patients with one, two and three vessel disease . Am J Cardiol. 1978;;42:839-848.
3 +
Varnauskas E and the European Coronary Surgery Study Group.  Twelve-year follow-up of survival in the randomized European Coronary Surgery Study . N Engl J Med. 1988;;319:332-337.
4 +
Coronary Artery Surgery Study (CASS) principal investigators and associates:  A randomized trial of coronary artery bypass surgery: survival data . Circulation . 1983;;68:939-950.
5 +
Takaro T, Hultgren HN, Lipton MJ, Detre KM, and participants in the study group.  The VA cooperative randomized study of surgery for coronary arterial occlusive disease, II: subgroup with significant left main lesion . Circulation . 1976;;54( (suppl 3) ):III-107—III-117.
6 +
Killip T, Passamani E, Davis K, CASS principal investigators and associates.  Coronary artery surgery study (CASS): a randomized trial of coronary bypass surgery: eight years follow-up and survival in patients with reduced ejection fraction . Circulation . 1985;;72( (suppl 5) ):V-102—V-109.
7 +
Bonow RO, Epstein SE.  Indications for coronary artery bypass surgery in patients with chronic angina pectoris: implications of the multicenter randomized trials . Circulation . 1985;;72( (suppl 2) ):II-23—II-30.
8 +
Rahimtoola SH.  A perspective on the three large multicenter randomized clinical trials of coronary bypass surgery for chronic stable angina . Circulation . 1985;;72( (suppl 2) ):II-123—II-125.
9 +
Killip T, Ryan TJ.  Randomized trials in coronary bypass surgery . Circulation . 1985;;71:418-421.
10 +
Graboys TB, Headley A, Lown B, Lampert S, Blatt CM.  Results of a second-opinion program for coronary artery bypass graft surgery . JAMA . 1987;;258:1611-1614.
11 +
Winslow CM, Kosecoff JB, Chassin M, Kanouse D, Brook RH.  The appropriateness of performing coronary artery bypass surgery . JAMA . 1988;;260:505-509.
12 +
Coronary Artery Surgery Study (CASS) Investigators.  Comparison of coronary artery bypass surgery and medical therapy in patients 65 years of age or older . N Engl J Med. 1985;;313:217-224.
13 +
Alderman EL, Fisher LD, Litwin P, et al.  Results of coronary artery surgery in patients with poor left ventricular function . Circulation . 1983;; 68:785-795.
14 +
Kirklin JW, Blackstone EH, Rogers WJ.  The plights of the invasive treatment of ischemic heart disease . J Am Coll Cardiol. 1985;;5:158-167.
15 +
Pigott JD, Kouchoukos NT, Oberman A, Cutler GR.  Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function . J Am Coll Cardiol. 1985;;5:1036-1045.
16 +
Kaiser GC, Davis KB, Fisher LD, et al.  Survival following coronary artery bypass grafting in patients with severe angina pectoris: an observational study . J Thome Cardiovasc Surg. 1985;;89:513-524.
17 +
Harris PJ, Harrell FE Jr, Lee KL, Behar VS, Rosati RA.  Survival in medically treated coronary artery disease . Circulation . 1979;;60:1259-1269.
18 +
Harrell FE Jr, Lee KL, Califf RM, Pryor DB, Rosati RA.  Regression modelling strategies for improved prognostic prediction . Stat Med. 1984;; 3:143-152.
19 +
Pryor DB, Harrell FE Jr, Lee KL, Califf RM, Rosati RA.  An improving prognosis over time in medically treated patients with coronary heart disease . Am J Cardiol. 1983;;52:444-448.
20 +
Califf RM, McKinnis RA, Burks JA, et al.  Prognostic implications of ventricular arrhythmias during 24 hour ambulatory monitoring in patients undergoing cardiac catheterization for coronary artery disease . Am J Cardiol. 1982;;50:23-31.
21 +
Califf RM, Conley MJ, Behar VS, et al.  'Left main equivalent' coronary artery disease: its clinical presentation and prognostic significance with nonsurgical therapy . Am J Cardiol. 1984;;53:1489-1495.
22 +
Trask N, Califf RM, Conley MJ, et al.  Accuracy and interobserver variability of coronary cineangiography: a comparison with postmortem evaluation . J Am Coll Cardiol. 1984;;3:1145-1154.
23 +
Rankin JS, Sabiston DC Jr.  Physiologic determinants of the coronary blood flow, cardiac metabolism and intraoperative myocardial protection . In: Sabiston DC Jr, ed. A Textbook of Surgery . 13th ed. Philadelphia, Pa: WB Saunders; 1986;:2281.
24 +
Rankin JS, Newman GE, Bashore TM, et al.  Clinical and angiographic assessment of complex mammary artery bypass grafting . J Thorac Cardiovasc Surg. 1986;;92:832-846.
25 +
Rankin JS, Newman GE, Muhlbaier LH, Behar VS, Fedor JM, Sabiston DC Jr.  The effects of coronary revascularization on left ventricular function in ischemic heart disease . J Thorac Cardiovasc Surg. 1985;;90:818-832.
26 +
Kaplan EL, Meier P.  Nonparametric estimation from incomplete observations . J Am Stat Assoc. 1958;;53:457-481.
27 +
Chaitman BR, Davis K, Fisher LD, et al.  A life table and Cox regression analysis of patients with combined proximal left anterior descending and proximal left circumflex coronary artery disease: non—left main equivalent lesions (CASS) . Circulation . 1983;;68:1163-1170.
28 +
Cox DR.  Regression models and life-tables (with discussion) . J R Stat Soc. 1972;;34(series B): 187-220.
29 +
Breslow N.  Covariance analysis of censored survival data . Biometrics . 1974;;30:89-99.
30 +
Harrell FE Jr.  The PHGLM procedure . In: SUGI Supplemental Library User's Guide: Version 5 Edition . Cary, NC: SAS Institute Inc; 1986;:437-466.
31 +
Pryor DB, Harrell FE Jr, Rankin JS, et al.  Trends in the presentation, management and survival of patients with coronary artery disease: the Duke Data Base for Cardiovascular Disease . In: Higgins MW, Luepker RV, eds. Trends in Coronary Heart Disease Mortality: Influence of Medical Care . New York, NY: Oxford University Press Inc; 1988;:76-87.
32 +
Pryor DB, Harrell FE Jr, Rankin JS, et al.  The changing survival benefits of coronary revascularization over time . Circulation . 1987;;76( (suppl 2) ):II-13-II-21.
33 +
Laupacis A, Sackett DL, Roberts RS.  An assessment of clinically useful measures of the consequences of treatment . N Engl J Med. 1988;;318: 1728-1733.
34 +
Rankin JS, Newton JR Jr, Califf RM, et al.  Clinical characteristics and current management of medically refractory unstable angina . Ann Surg. 1984;;200:457-464.
35 +
Califf RM, Hlatky MA, Mark DB, et al.  Randomized trials of coronary artery bypass surgery: impact on clinical practice at Duke University Medical Center . Circulation . 1985;;72( (suppl 2) ):II-136— II-143.
36 +
Whalen RE, Harrell FE Jr, Lee KL, Rosati RA.  Survival of coronary artery disease patients with stable pain and normal left ventricular function treated medically or surgically at Duke University . Circulation . 1982;;65( (suppl 2) ):II-49—II-52.
37 +
Hlatky MA, Califf RM, Harrell FE Jr, Lee KL, Mark DB, Pryor DB.  Comparison of predictions based on observational data with the results of randomized controlled clinical trials of coronary artery bypass surgery . J Am Coll Cardiol. 1988;; 11:237-245.
38 +
Loop FD, Lytle BW, Cosgrove DM, et al.  Influence of the internal mammary artery on 10-year survival and other cardiac events . N Engl J Med. 1986;;314:1-9.
39 +
Califf RM, Pryor DB, Greenfield JC.  Beyond randomized clinical trials: applying clinical experience in the treatment of patients with coronary artery disease . Circulation . 1986;;74:1191-1194.
40 +
Mantel N.  Cautions on the use of medical databases . Stat Med. 1983;;2:355-362.
41 +
Byar DP.  Why databases should not replace randomized clinical trials . Biometrics . 1980;;36:337-342.
42 +
Yusuf S, Witter J, Bailey K, Furberg C.  Digitalis—a new controversy regarding an old drug: the pitfalls of inappropriate methods . Circulation . 1986;;73:14-18.
43 +
Lee KL, McNeer JF, Starmer CF, Harris PJ, Rosati RA.  Clinical judgment and statistics: lessons from a simulated randomized trial in coronary artery disease . Circulation . 1980;;61:508-515.
44 +
Hlatky MA, Lee KL, Harrell FE Jr, et al.  Tying clinical research to patient care by use of an observational database . Stat Med. 1984;;3:375-384.
45 +
Hammermeister KE, DeRouen TA, Dodge HT.  Comparison of survival of medically and surgically treated coronary disease patients in Seattle Heart Watch: a nonrandomized study . Circulation . 1982;;65( (suppl 2) ):II-53—II-59.
46 +
Ringqvist I, Fisher LD, Mock M, et al.  Prognostic value of angiographic indices of coronary artery disease from the Coronary Artery Surgery Study (CASS) . J Clin Invest. 1983;;71:1854-1866.
47 +
Harrell FE Jr, Pollack BG, Lee KL.  Graphical methods for the analysis of survival data . In: Proceedings of the Twelfth Annual SAS User's Group International Conference . Cary, NC: SAS Institute Inc; 1987;:1107-1115.
48 +
Mantel N.  Evaluation of survival data and two new rank order statistics arising in its consideration . Cancer Chemother Rep. 1966;;50:163-170.
49 +
Miller RG. Survival Analysis . New York, NY: John Wiley & Sons Inc; 1980;.
50 +
Tibshirani R.  A plain man's guide to the proportional hazards model . Clin Invest Med. 1982;; 5:63-68.
51 +
Lee KL, Harrell FE Jr, Tolley HD, Rosati RA.  A comparison of test statistics for assessing the effects of concomitant variables in survival analysis . Biometrics . 1983;;39:341-350.
52 +
Kalbfleisch JD, Prentice RL. The Statistical Analysis of Failure-Time Data . New York, NY: John Wiley & Sons Inc; 1980;.
53 +
Makuch RW.  Adjusted survival curve estimation using covariates . J Chronic Dis. 1982;;35:437-443.

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