Comparison of survival of medically and surgically treated coronary disease patients in Seattle Heart Watch: a nonrandomized study

Surgical myocardial revascularization

In conclusion, surgical myocardial revascularization has utilized diverse methods to increase blood flow to the starving myocardium. These methods initially used the microcirculation as the portal to reach myocytes until angiography showed that the obstructions were macrovascular. This resulted in a 30-year era of direct attack on the coronary blockages by coronary bypass. Surgical conduits unfortunately have longevity considerably less than that of native arteries and are limited in number. Alternative conduits, both biologic and prosthetic, have not yet proved to have the same clinical results as the ITA. More patients are living long enough to have the extensiveness of their disease exhaust conventional therapies. Newer therapy, restricted thus far to untreatables, revisits the microcirculation by making laser channels. These many innovative procedures have benefited hundreds of thousands of patients. They emerged from the probity and innovation of many individual surgeons.

Rating the quality of evidence for clinical practice guidelines

This article describes the system for rating the quality of medical evidence developed and used during creation of the Agency for Health Care Policy and Research-sponsored heart failure guideline. Previous approaches to rating evidence were not designed for use in the setting of clinical practice guidelines. The present system is based on the tenet that flaws in research design are serious to the extent they threaten the validity of the results of studies. A taxonomy of major and minor flaws based on that tenet was developed for randomized controlled trials and for cohort and medical registry studies. The use of the system is described in the context of two difficult clinical issues considered by the Panel: the role of coronary artery revascularization and the use of metoprolol.

Comparison of cost-effectiveness and utility of exercise ECG, single photon emission computed tomography, positron emission tomography, and coronary angiography for diagnosis of coronary artery disease

BACKGROUND

To compare cost-effectiveness and utility of four clinical algorithms to diagnose obstructive coronary atherosclerotic heart disease (CAD), we compared exercise ECG (ExECG), stress single photon emission computed tomography (SPECT), positron emission tomography (PET), and coronary angiography.

METHODS AND RESULTS

Published data and a straightforward mathematical model based on Bayes' theorem were used to compare strategies. Effectiveness was defined as the number of patients with diagnosed CAD, and utility was defined as the clinical outcome, ie, the number of quality-adjusted life years (QALY) extended by therapy after the diagnosis of CAD. Our model used published values for costs, accuracy, and complication rates of tests. Analysis of the model indicates the following results. (1) The direct cost (fee) for each test differs considerably from total cost per delta QALY. (2) As pretest likelihood of CAD (pCAD) in the population increases, there is a linear increase in cost per patient tested but a hyperbolic decrease in cost per effect and cost per utility unit, ie, increased cost-effectiveness and decreased cost per utility unit. (3) At pCAD < 0.70, analysis of the model indicates that stress PET is the most cost-effective test, with the lowest cost per utility, followed by SPECT, ExECG, and angiography, in that order. (4) Above a threshold value of pCAD of 0.70 (for example, middle-aged men with typical angina), proceeding directly to angiography as the first test showed the lowest cost per effect or utility. This quantitative model has the advantage of estimating a threshold value of pCAD (0.70) at which the rank order of cost-effectiveness and cost per utility unit change. The model also allows substitution of different values for any variable as a way to account for the uncertainties of clinical data, ie, changing costs, test accuracy and risk, etc. This procedure, called sensitivity analysis, showed that the rank order of cost-effectiveness did not change despite changes in several variables.

CONCLUSIONS

(1) Estimation of total costs of diagnostic tests for CAD requires consideration not only of the direct cost of the test per se (eg, test fees) but also of the indirect and induced costs of management algorithms based on the test (eg, cost/delta QALY). (2) It is essential to consider the clinical history (pCAD) when selecting the clinical algorithm to make a diagnosis with the lowest cost per effect or cost per utility unit. (3) Stress PET shows the lowest cost per effect or cost per utility unit in patients with pCAD < 0.70. (4) Angiography shows the lowest cost per effect or cost per utility unit in patients with pCAD > 0.70.

Clinical judgment and therapeutic decision making

Clinical decision making is under increased scrutiny due to concerns about the cost and quality of medical care. Variability in physician decision making is common, in part because of deficiencies in the knowledge base, but also due to the difference in physicians' approaches to clinical problem solving. Evaluation of patient prognosis is a critical factor in the selection of therapy, and careful attention to methodology is essential to provide reliable information. Randomized controlled clinical trials provide the most solid basis for the establishment of broad therapeutic principles. Because randomized studies cannot be performed to address every question, observational studies will continue to play a complementary role in the evaluation of therapy. Randomized studies in progress, meta analyses of existing data, and increased use of administrative and collaborative clinical data bases will improve the knowledge base for decision making in the future.

Fifteen-year results of coronary artery bypass for isolated left anterior descending coronary artery disease

During 1971 through 1975, 266 patients underwent primary coronary artery bypass grafting for occlusive disease confined to the left anterior descending coronary artery. Actuarial survival at 15 years was 72.7% with 60% of survivors being free from angina. Although the cause of death was cardiac related in 50% of the patients who died, survival was comparable with that of an age-matched and sex-matched general population. During follow-up, 48 secondary or tertiary repeat coronary artery bypass as well as 44 percutaneous transluminal coronary angioplasty procedures were performed. Acute event-free status (freedom from acute myocardial infarction, repeat coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, or death) persisted at 15 years in 43.2% of patients. The differences in survival when patients were segregated according to age, sex, number of grafts performed, or graft conduit (internal mammary artery versus vein) were not significant. However, comparison of graft conduits revealed a significantly better (p = 0.02) overall acute event-free survival when the internal mammary artery was used.

Twelve-year follow-up of survival in the randomized European Coronary Surgery Study

We studied survival rates among 767 men with good left ventricular function who participated in the European Coronary Surgery Study, 10 to 12 years after they were randomly assigned to either early coronary bypass surgery or medical therapy. At the projected five-year follow-up interval, we observed a significantly higher survival rate (+/- 95 percent confidence interval) in the group that was assigned to surgical treatment than in the group assigned to medical treatment (92.4 +/- 2.7 vs. 83.1 +/- 3.9 percent; P = 0.0001). During the subsequent seven years, the percentage of patients who survived decreased more rapidly in the surgically treated than in the medically treated group (70.6 +/- 5.8 vs. 66.7 +/- 5.3 percent at 12 years). Thus, the improvement in the survival rate among patients with stable angina who were treated surgically appears to have been attenuated after five years. However, the gradually diminishing difference between the two survival curves still favored surgical treatment after 12 years (P = 0.04), despite the fact that 136 patients in the medically treated group had coronary bypass surgery and 23 in the "surgically treated" group did not. The benefit of surgical treatment tended to be greater, but not significantly so, as assessed by interaction analysis in the subgroups of patients who were older or who had signs of ischemia or previous infarction on the resting electrocardiogram, a markedly ischemic response to exercise testing, peripheral arterial disease, an absence of hypertension, and proximal obstruction in the left anterior descending artery. The reasons for the loss of a beneficial effect of surgery after five years are unknown and merit further study.

Effect of aortocoronary bypass surgery on coronary circulation and myocardial metabolism during atrial pacing

Eleven patients with coronary heart disease, in whom at least one of several bypass grafts to the left coronary artery was patent, were selected for the study. The hemodynamics, coronary sinus blood flow, myocardial oxygen consumption, and myocardial lactate metabolism were evaluated at rest and during atrial pacing stress test before and after surgery. There were no significant improvements in the cardiac index, pulmonary arterial end-diastolic pressure, and left ventricular ejection fraction after aortocoronary bypass surgery. However, significant improvement of coronary sinus blood flow, myocardial oxygen consumption, and myocardial lactate extraction and consumption were found during postoperative atrial pacing compared with the preoperative findings. These results suggest that successful bypass grafting may improve myocardial lactate metabolism in ischemic lesions and contribute to the postoperative relief of angina.

Medical versus early surgical therapy in patients with triple-vessel disease and mild angina pectoris: a CASS registry study of survival

Results of coronary artery bypass grafting were evaluated in 856 nonrandomized patients in the Coronary Artery Surgery Study (CASS) registry with mild angina (Canadian Cardiovascular Society Classes I and II) and three-vessel disease, defined as 70% or more stenosis in the proximal or middle segment of the three major coronary arteries. There were 413 patients with medical therapy and 443 with early operation. Patients with delayed operation were kept in the medical group for analysis. Six-year survival adjusted for left ventricular (LV) function and number of proximal stenoses was 67% for medical and 84% for surgical patients (p less than 0.0001). Patients with normal LV function had equal survival with medicine or surgical intervention. Those with mild or moderate LV dysfunction (CASS LV wall motion score 6 to 9 and 10 to 15, respectively) and at least one proximal stenosis (the dominant right coronary artery) had increased probability of being alive at six years with surgical treatment. In patients with severe LV impairment (LV score higher than 15) and in those whose only proximal stenosis of 70% or more (in three-vessel disease) was located in the left anterior descending coronary artery, increased survival with surgical treatment could not be demonstrated. This is a nonrandomized observational study with the limitations of such studies: the need to adjust for differences in baseline traits between medical and surgical groups and the possibility of an unrecognized imbalance in baseline characteristics. In a Cox analysis of variables influencing outcome, early surgical treatment was an independent predictor of survival with 43% the risk of medical treatment (95% confidence range: 29 to 62%). Adjustment by propensity analysis to reduce selection bias from known differences in baseline variables did not alter results.

Determinants of survival 10 to 14 years after coronary bypass: analysis of preoperative variables in 1,448 patients

To determine which preoperative variables were most predictive of long-term survival after coronary bypass surgery, the status of 1,448 consecutive patients was determined 10 to 14 years after operation. All patients were operated on at least 10 years ago and follow-up at 10 years was 93.8% complete. The overall 14-year survival probabilities were: for one-vessel disease, 73.3%; for two-vessel disease, 45.9%; for three-vessel disease, 34.2%; and for left main coronary artery disease, 41.9%. Patients with good left ventricular function had an overall survival rate of 53.3%, and patients with poor ventricular function had a survival rate of 31.9%. Preoperative variables predictive of greater risk of total mortality were: digoxin usage, multivessel disease, poor quality of left ventricular function, age at operation, electrocardiographic evidence of myocardial infarction, previous stroke, diabetes, heart failure, diuretic usage, cigarette smoking, and residual ungrafted coronary artery disease. The major determinants of long-term survival were variables associated with preoperative left ventricular function. Diabetes was the only important metabolic risk factor identified. This study suggests that unfavorable preoperative conventional risk factors should not be considered a contraindication to operation in patients with adequate coronary anatomy and left ventricular function.

Clinical significance of exercise-induced silent myocardial ischemia in patients with coronary artery disease

Exercise-induced silent myocardial ischemia is a frequent feature in patients with coronary artery disease. The purpose of this study was to compare the clinical and angiographic characteristics of 269 patients who complained of chest pain during an exercise test (group I) with those of 204 who developed exercise-induced silent myocardial ischemia (group II). Group I patients more frequently had anginal symptoms of class III and IV of the Canadian Cardiovascular Society than did group II patients, who had milder symptoms (p less than 0.001). The only angiographic difference observed between the two groups was a slightly but significantly higher left ventricular end-diastolic pressure in group II patients (p less than 0.05), who also showed a longer exercise duration (p less than 0.01) with a higher heart rate-systolic pressure product (p less than 0.01) and more pronounced ST segment depression at peak exercise (p less than 0.001). Moreover, ventricular ectopic beats during exercise were more frequently observed in group II patients (p less than 0.05). Coronary bypass surgery was performed in 45% of patients of group I and in 24% of patients of group II (p less than 0.05). Survival curves of medically treated patients did not show any statistically significant difference between the two groups. Thus, although patients with a defective anginal warning system may have more pronounced signs of myocardial ischemia and a greater incidence of ventricular arrhythmias during exercise, their long-term prognosis is not different from that of patients who are stopped by angina from the activity that is inducing myocardial ischemia.

The effect of medical and surgical treatment on subsequent sudden cardiac death in patients with coronary artery disease: a report from the Coronary Artery Surgery Study

The effect of medical and surgical treatment on subsequent sudden cardiac death was assessed in 13,476 patients in the Coronary Artery Surgery Study registry who had significant coronary artery disease, operable vessels, and no significant valvular disease. (Patients were assigned to medical or surgical therapy on the basis of clinical judgment and not according to a randomization scheme; therefore, biases associated with unknown variables could not be evaluated.) Sudden cardiac death occurred in 452 patients (3.4%) during a mean follow-up of 4.6 years. Five year survival free of sudden death for medically treated patients was 94 +/- 0.3%, and that for surgically treated patients was 98 +/- 0.2% (p less than .0001). Twelve baseline clinical, electrocardiographic, and angiographic variables were significantly different between patients alive at the last follow-up and those suffering sudden death. Data on these variables were available for 11,508 patients. Sudden death occurred in 257 (4.9%) of 5258 medically treated and 101 (1.6%) of 6250 surgically treated patients. In a high-risk patient subset with three-vessel disease and history of congestive heart failure, 91% of surgically treated patients had not suffered sudden death compared with 69% of medically treated patients. After Cox survival analysis was used to correct for baseline variables, surgical treatment had an independent effect on sudden death (p less than .0001). This reduction was most pronounced in high-risk patients.

Bypass grafting to the right coronary artery with and without endarterectomy: patency at one year

Between January 1979 and December 1981, 142 patients undergoing surgery to the right coronary artery agreed to have repeat coronary arteriography one year later. Thirty patients underwent combined endarterectomy and bypass grafting to the right coronary artery. The patency of these grafts was compared with that of grafts in 69 patients undergoing direct grafting to the right coronary artery and in 43 with grafting to the posterior descending coronary artery. There were two hospital deaths and one late death. No patients developed new inferior Q waves on the electrocardiogram. Repeat coronary arteriography at one year showed that 21 (72%) of the 29 grafts were patent after combined endarterectomy and bypass grafting to the right coronary artery. Sixty three (94%) grafts to the right coronary artery and 40 (93%) grafts to the posterior descending coronary artery were patent at one year. Direct grafts to the right coronary artery or its posterior descending branch had a significantly higher patency rate at one year than grafts to the endarterectomised right coronary artery. Graft patency after the combined procedure correlated with the extent of atherosclerosis in the posterior descending coronary artery. It was not influenced by treatment with platelet antagonists. Endarterectomy of the right coronary artery was most successful when it allowed a single graft to perfuse both the large posterior descending and left ventricular branches.

Twelve-year experience with bilateral internal mammary artery grafts

A 12 1/2-year experience with 227 patients who underwent coronary revascularization with bilateral internal mammary artery (IMA) and supplemental saphenous vein grafts is presented. There were 725 coronary grafts performed (3.2 per patient). Forty-four IMA grafts were sequential. In 42 patients, the right IMA was placed through the transverse sinus to revascularize the circumflex artery. Operative mortality was 4% (9 of 227 patients). Postoperative complications included sternal infection (4 patients), reexploration for bleeding (5), and diaphragmatic dysfunction (10). Postoperative arteriography in 30 patients (mean interval, 4 1/4 years) revealed that 92% (34/37) of the left IMA and 87% (26/30) of the right IMA grafts were patent. Late follow-up was complete in 207 surviving patients. Eighteen late deaths (9 cardiac and 9 noncardiac) occurred. Actuarial survival was 83% at 10 years after operation. Of 68 patients followed from 8 to 12 1/2 years (mean interval, 10 1/2 years), 69% were asymptomatic, and 28% were in New York Heart Association Functional Class II. We conclude that bilateral IMA grafting can be accomplished with low operative risk and provides excellent long-term results.

Surgical survival in the Coronary Artery Surgery Study (CASS) registry

The overall surgical survival data in the Coronary Artery Surgery Study (CASS) registry have not been published to date, pending the report of the randomized medical-surgical comparison (CASS randomized trial). Non-randomized surgical survival data from the CASS registry are given in this article. The overall medical survival data from the registry were reported previously as a natural history study. There were 8,991 patients in the registry portion of CASS who had primary isolated coronary artery bypass grafting and 8,971 with follow-up of more than 30 days. The 5-year survival for all 8,971 patients was 90%, and the operative mortality was 2.37%. Patients with left main coronary artery disease had an operative mortality of 3.84% and a 5-year survival of 85%, while patients with lesions in other vessels had an operative mortality of 2.12% and a 5-year survival of 91%. Among patients without left main coronary disease, the 5-year survival was 93% in those with single-vessel and 92% in those with double-vessel disease (operative mortality was 1.50% and 1.92%, respectively) and 88% in patients with triple-vessel disease (operative mortality was 2.62%; p = 0.009). When results for patients with left main coronary artery obstruction were compared with those for triple-vessel disease, the 5-year survival figures were 85% and 88%, respectively (p = 0.02) and the operative mortality, 3.84% and 2.62%, respectively (p = 0.03). Patients with normal or nearly normal left ventricular (LV) function (i.e., LV segmental wall motion scores ranging from 5 through 11) had a 5-year survival of 92% and an operative mortality of 1.97%. Patients with moderate impairment (LV score range, 12 through 16) had a 5-year survival of 80% and an operative mortality of 4.21%. In those with poor ventricular function (LV score of 17 or greater), the 5-year survival was 65% and the operative mortality was 6.21%. The difference in survival among the three groups was significant (p less than 0.0001). Of 29 variables used in a stepwise Cox regression analysis, LV wall motion score, congestive heart failure score, age, number of operable vessels, smoking history, LV end-diastolic pressure, and percent of left main coronary artery stenosis were found to have a significant effect on long-term survival (excluding 30-day mortality), and these variables plus surgical priority and height influenced surgical mortality. When height was used in the Cox proportional hazards model, female sex was no longer a significant variable.

The decision concerning coronary angiography in patients with chest pain. A cost-effectiveness analysis

We examined the decision whether to perform coronary angiography (followed by bypass surgery if appropriate findings are present) in middle-aged men who have chest pain and have undergone exercise tolerance testing (ETT). We developed a model of this decision that combines data from a variety of sources and selects the optimal strategy based on health outcome and, if desired, monetary cost. The analysis supports the following conclusions: for patients with nonspecific chest pain or atypical angina, the ETT provides useful information concerning the decision; furthermore, the number of millimeters of ST-segment depression above which angiography should be performed depends on coronary risk factors and pain severity. A normal ETT is insufficient evidence to exclude coronary angiography for patients with typical angina, provided that one is willing to expand resources for health benefits at levels comparable to those for other accepted medical practices. If monetary considerations are excluded, the preceding statement concerning ETT and angiography also holds for patients with atypical angina and for those with nonspecific pain and advanced risk factors. These last two conclusions suggest that ETT is not useful in guiding management decisions concerning coronary angiography in patients at high enough risk of coronary artery disease on the basis of symptoms and risk profile.

Comparison of coronary artery bypass surgery and medical therapy in patients 65 years of age or older. A nonrandomized study from the Coronary Artery Surgery Study (CASS) registry

We compared the results of coronary artery bypass surgery with those of medical therapy alone in 1491 nonrandomized patients 65 years of age or older. Cumulative survival at six years (adjusted for major differences in important base-line characteristics) was 79 per cent in the surgical group and 64 per cent in the medical group (P less than 0.0001). At five years, chest pain was absent in 62 per cent of the surgical group and 29 per cent of the medical group (P less than 0.0001). Analysis by the Cox proportional-hazards model suggested an independent beneficial effect of surgery on survival (P less than 0.0001). Patients were divided into risk quartiles on the basis of preoperative predictors of survival identified by the Cox model. Surgical benefit was greatest in "high-risk" patients (those in the two quartiles containing patients with the poorest prognosis). Among 234 "low-risk" patients with mild angina, relatively good ventricular function, and no left main coronary artery disease, there was no survival difference between those treated medically and those treated surgically. We conclude that in specific higher-risk subsets of non-randomized patients 65 years of age or older, coronary bypass surgery appeared to improve survival and symptoms in comparison with medical therapy alone. These conclusions must be tempered by consideration of the limitations of nonrandomized studies, particularly since patients in the two treatment groups differed substantially with regard to important base-line characteristics.

The place of coronary artery bypass surgery: an appraisal

The enthusiasm for performing coronary artery bypass graft (CABG) surgery in Australia is increasing. The results of a number of careful trials which have compared surgical with medical treatment have now appeared. While there is agreement on both the increased survival provided by CABG surgery in those with left main coronary artery stenosis and the relief of symptoms in patients in whom medical therapy has failed to control severe angina, there is debate about the value of surgery in other types of disease. With improvements in medical therapy, the most recent trials have failed to show a significant overall survival benefit from surgery, although it is generally considered that surgery can relieve angina and that, in at least some groups of persons with stenosis of all three main coronary vessels (triple-vessel disease), surgery may prolong life. Alternative methods of prolonging survival among people with ischaemic heart disease include the reduction of risk factors (such as hypertension, raised blood cholesterol levels and cigarette smoking), as well as treating patients with beta-blocking agents after a myocardial infarction. We suggest it is likely that a combination of these approaches could be more effective in terms of lives saved than is CABG and may be less expensive. The current expansion of CABG surgery in Australia should be viewed in this light.

Current status of coronary artery bypass grafting for coronary artery atherosclerosis

Coronary artery bypass grafting has now undergone 18 years of proven benefit in the treatment of myocardial ischemic disease. The technique of CABG has been further extended to other situations in which myocardial blood supply is threatened, such as cardiac trauma, aneurysms of coronary arteries, and congenital lesions. The emphasis in choosing CABG over medical therapy in 1985 should be preservation of myocardium at jeopardy of infarction as well as relief of angina. Proximal stenoses in vessels subserving viable muscle that is ischemic at rest or with minimal exercise should be treated with reperfusion by angioplasty or CABG to prevent further injury. After infarction occurs and ventricular function is impaired, CABG is also necessary to preserve remaining myocardium at jeopardy. Such an aggressive approach seems warranted with today's excellent surgical results. Long-term results have also improved, as more attention has been paid to saphenous vein graft preparation, use of mammary artery grafts, complete revascularization, use of antiplatelet agents, control of spasm, and identification of hypercoagulable states that may require sodium warfarin (Coumadin). Angioplasty of vein grafts and distal anastomoses also appears promising to help extend the results of initial CABG. Figure 1 is our recommended approach for the treatment of coronary atherosclerosis.

Is there an indication for coronary angiography in patients under 60 years of age with no or minimal angina pectoris after a first myocardial infarction?

Coronary angiography and exercise stress tests were performed in 91 consecutive patients under 60 years of age having either no or only mild angina pectoris with or without medication after a first myocardial infarction. Nine (10%) patients had angiographic high risk coronary artery disease defined as three vessel disease, left main stenosis, or proximal stenosis of the left anterior descending artery. Eighteen patients had a positive electrocardiographic exercise stress test including eight of the nine patients with angiographic high risk coronary artery disease. It may be concluded therefore that coronary angiography to detect high risk coronary artery disease in this group can be restricted to patients with a positive exercise stress test. This policy would obviate the need for about 80% of coronary angiograms performed in this age group.

Association between early graft patency and late outcome for patients undergoing artery bypass graft surgery

For a group of 658 patients who received coronary artery bypass graft surgery, we investigated the correlation between the degree of early (6 months) graft patency and recurrence of anginal symptoms, late myocardial infarction, and postoperative coronary-related death. The patients were grouped according to the number of surgically placed grafts, and each group was further subgrouped on the basis of the number of grafts functioning at the early postsurgical follow-up examination. The patients were observed over a period as long as 13 years. The frequency with which angina returned correlated significantly with the degree of patency within each of the groups (one, two, three, or four grafts); patients with a higher percentage of patent grafts experienced longer periods of freedom from angina. On the average, patients with all of their multiple grafts patent experienced at least 7 more years of symptomatic relief than their counterparts with all grafts occluded. Most surprisingly, the rate of the return of angina for those patients who had all grafts patent and were completely revascularized was independent of the number of diseased vessels or the number of grafts placed. The findings for coronary death and postoperative infarction showed similar trends.

Fifteen year survival study of patients with obstructive coronary artery disease

Survival rates were determined for a group of 598 patients in whom severe coronary disease was demonstrated by arteriography; initially they were treated medically and were followed-up for 15 years. Deaths due to noncoronary causes were uncommon (5% of total) in the first 5 year period but were frequent (36%) in the third period. Survival rates were 48%, 28%, 18%, and 9% for patients with single-, double-, triple-, and left main artery disease, respectively. Abnormalities documented by ventriculography were related to survival. In 386 patients who would have been candidates for bypass surgery, survival rates were 58%, 35%, 26%, and 11% for those with single-, double-, triple-, and left main artery disease, respectively. Cardiac survival curves for single-, double-, and triple-artery disease in candidates for surgery and curves constructed on the basis of 3% mortality per artery per year corresponded fairly closely. When an abnormal electrocardiogram (ECG) is considered as a single variable in multivariate analysis, 5 year survival rates of candidates for surgery were influenced by the following in order of importance: abnormal ECG, symptoms at least 5 years in duration, triple-artery disease, double-artery disease, and arteriosclerosis obliterans. A simple prognostic stratification was devised that used only ECGs and duration of symptoms for each subset based on the number of arteries affected.

Uncomplicated acute myocardial infarction: long-term management

The components of long-term management of the patient recovered from uncomplicated myocardial infarction include identification and alteration of nonatherosclerotic factors that might increase the risk of early reinfarction or sudden coronary death, alteration of modifiable coronary atherosclerotic risk factors to prevent progression or induce regression of the atherosclerotic process, and optimal restoration and maintenance of residual cardiovascular function to help improve the quality of life of the patient.