Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators.

BACKGROUND: The Bypass Angioplasty Revascularization Investigation (BARI) included 4039 patients with multivessel coronary artery disease; 1829 consented to randomization, and 2010 did not but were followed up in a registry. Thus, we can evaluate the outcome of physician-guided versus random assignment of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft surgery (CABG). METHODS AND RESULTS: We compared the baseline features and outcomes for PTCA and CABG in the overall registry and its predesignated subgroups. We assessed the impact of treatment by choice versus random assignment by comparing the results in the registry with those of the randomized trial. Statistical adjustments for differences in baseline characteristics were made. Within the registry, nearly twice as many patients were selected for PTCA (1189) as CABG (625); mortality at 7 years was similar for PTCA (13.9%) and CABG (14.2%) (P=0.66) before and after adjustment for baseline differences between patients selected for PTCA versus CABG (adjusted RR, 1.02; P=0.86). In contrast to the randomized trial, the 7-year mortality rate of treated diabetics in the registry was equally high (26%) with PTCA or CABG. Seven-year mortality was higher for patients undergoing PTCA in the randomized trial than in the registry (19.1% versus 13.9%, P<0.01) but not for those undergoing CABG (15.6% versus 14.2%, P=0.57). The adjusted relative mortality risk for PTCA in the randomized versus registry population was 1.17 (P=0.16). CONCLUSIONS: BARI physicians were able to select PTCA rather than CABG for 65% of registry patients who underwent revascularization without compromising long-term survival either in the overall population or in treated diabetics.

Increased incidence of periprocedural complications among patients with peripheral vascular disease undergoing myocardial revascularization in the bypass angioplasty revascularization investigation.

BACKGROUND: Risks of coronary artery bypass graft surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) may be different in the presence of peripheral vascular disease (PVD). METHODS AND RESULTS: We analyzed outcomes of 550 patients with PVD enrolled in the Bypass Angioplasty Revascularization Investigation randomized trial and registry. Compared with 1770 patients without PVD, those with PVD were older and had a greater prevalence of medical comorbid conditions. No significant differences in coronary anatomy or PTCA success rates were found. The risk of any major complication (death, myocardial infarction, stroke, coma, or emergency revascularization) after PTCA was significantly higher among patients with PVD (11.7% versus 7.8%, P=0.027). In multivariate analysis, this represented a 50% increase in the odds of having any major complication (multivariate odds ratio, 1.5; P=0. 032). Among patients undergoing CABG, the risk of major complications was found to be markedly higher for patients with PVD (12%) than those without (6.1%, P=0.003) even after controlling for baseline differences (multivariate odds ratio, 1.8; P=0.018). Major differences between the PTCA and CABG groups were related primarily to a higher risk of neurological complications in PVD patients who had CABG (multivariate odds ratio, 2.8; P<0.001). CONCLUSIONS: We conclude that patients with PVD are at high risk for periprocedural complications after myocardial revascularization, in particular neurological events.

Effect of age in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial.

BACKGROUND: The influence of age on the relative success of either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients requiring myocardial revascularization continues to be controversial. METHODS: In the Bypass Angioplasty Revascularization Investigation (BARI) trial, 1,829 patients with symptomatic multivessel coronary artery disease requiring revascularization were randomly assigned to undergo either CABG or PTCA. RESULTS: Seven hundred nine patients (39%) were 65 to 80 years old at baseline; the other 1,120 were younger than 65 years. The in-hospital 30-day mortality rate for PTCA and CABG in the younger patients was 0.7% and 1.1%, respectively, and that for patients 65 years or older was 1.7% and 1.7%, respectively. In older compared with younger patients, stroke was more common after CABG (1.7% versus 0.2%, p = 0.015) and heart failure or pulmonary edema was more common after PTCA (4.0 versus 1.3%, p = 0.011). In both age groups, CABG resulted in greater relief of angina and fewer repeat procedures. The 5-year survival rate in patients younger than 65 years was 91.5% for CABG and 89.5% for PTCA. In patients 65 years or older, the 5-year survival rate was 85.7% for CABG and 81.4% for PTCA. Cardiac mortality at 5 years was greater in patients assigned to the PTCA group than in those assigned to the CABG group. However, no significant treatment differences were noted in cardiac mortality when only nondiabetic patients were examined. CONCLUSIONS: Within the context of the Bypass Angioplasty Revascularization Investigation trial, older patients with multivessel coronary disease do well with either PTCA or CABG. Compared with younger patients, older patients had less recurrent angina and were less likely to undergo repeat procedures, particularly among those assigned to undergo CABG. Cardiac mortality was greater in patients 65 years or older assigned to undergo PTCA; however, this difference was not noted when treated diabetic patients were excluded from analysis.

Coronary artery disease in the geriatric population.

The elderly represent an increasingly important and challenging subset of the population of patients with ischemic heart disease. They are more likely to have comorbid conditions, atypical presentations, and unfavorable outcomes than their younger counterparts. Some of these findings are undoubtedly related to the structural and functional changes in the cardiovascular system associated with aging. The available data suggest that standard pharmacologic, thrombolytic, and definitive revascularization techniques have important roles in the therapy of geriatric patients but have been underused.

Transesophageal versus transthoracic echocardiography in the evaluation of right atrial tumors.

The purpose of this study was to define the contribution of transesophageal echocardiography to the diagnosis of right atrial tumors in a large series of patients with this rare finding. Transesophageal echocardiography (TEE) has been found to be valuable in evaluating patients with intracardiac masses and has been shown to be superior to transthoracic echocardiography (TTE) in evaluating left heart masses. Between 1989 and 1993, 23 patients with either known tumors elsewhere or right atrial masses that were detected on TTE were evaluated with TEE. TEE studies were performed in the noninvasive cardiology laboratory. All patients were studied with 5 MHz biplane or omniplane transducers. The right atrium was evaluated for the presence, characteristics, extent, and attachment of any masses and for extension of these masses into the great vessels or other cardiac chambers. No complications occurred. Six patients had primary right atrial tumors. In 10 patients the tumors reached the right atrium via the inferior vena cava. Seven patients had malignant secondary tumors. TEE demonstrated three tumors not detected by TTE. Furthermore TEE provided 16 additional findings not seen on TTE. In conclusion, TEE is superior to TTE in the evaluation of right atrial tumors. TEE should be considered in patients with right atrial tumors even when these tumors have been demonstrated with TTE.

Atherosclerotic heart disease in the elderly.

The elderly represent an increasingly important and challenging subset of the population of patients with ischemic heart disease. They are more likely to have comorbid conditions, atypical presentations, and unfavorable outcomes. Some of these features are undoubtedly related to the structural and functional changes in the cardiovascular system associated with aging. The available data suggest that standard pharmacologic, thrombolytic, and definitive revascularization techniques have important roles in the treatment of these patients, but have been underused.

Comparison of HIV-antibody prevalence in patients consenting to and declining HIV-antibody testing in an STD clinic.

All patients attending a sexually transmitted disease (STD) clinic were offered voluntary, anonymous human immunodeficiency virus (HIV)-antibody testing and counseling as part of routine clinical evaluation. During a three-month evaluation period, 82% of patients accepted HIV testing. Testing was accepted equally by men and women and by heterosexual and homosexual men. Black men were more likely to refuse testing than men from other ethnic groups. Eight (0.7%) of 1146 STD clinic patients tested were infected with HIV. A blinded study of 237 patients who refused testing identified nine (3.8%) additional HIV-infected patients. Men who refused testing were 5.3 times more likely to be infected than men who accepted testing. Male homosexuals and black and Hispanic men who refused testing were 7.3 and 8.8 times, respectively, more likely to be infected with HIV than were their counterparts who accepted testing. Human immunodeficiency virus testing and counseling should be routinely offered to STD clinic patients. Male STD clinic patients, especially homosexual or minority men, who refuse voluntary HIV testing should be counseled regarding reducing their risk for HIV transmission.

KIE: Results of voluntary, anonymous human immunodeficiency virus (HIV) antibody testing and counseling offered to all patients attending a sexually transmitted disease (STD) clinic showed that men who refused testing were 5.3 times more likely to be infected than men who accepted testing, and that male homosexuals and black and Hispanic men who refused testing were even more likely to be infected than their counterparts who accepted testing. The prevalence of HIV infection in persons refusing HIV testing was determined in a retrospective, blinded study using stored serum specimens originally drawn for syphilis testing. It is recommended that HIV testing and counseling should be routinely offered to STD clinic patients; male STD clinic patients who refuse voluntary HIV testing should be counseled about reducing their risk for HIV transmission.