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Background: Previous studies investigating the appropriateness of invasive management of coronary disease had not reported the internal consistency of their ratings and may now be out of date. The aim of this study was to measure the influence of clinical factors on contemporary ratings of the appropriateness of coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) in the Appropriateness of Coronary Revascularisation (ACRE) study., Methods: The Delphi-RAND technique was used, in which an expert panel (four cardiologists, three cardiothoracic surgeons, a general physician and a general practitioner), meeting in 1995, rated mutually exclusive indications (n = 2178 for angiography, n = 995 for PTCA and n = 984 for CABG). The main outcome measures were the appropriateness category (inappropriate, uncertain or appropriate) for each of the three procedures and treatment preference., Results: For revascularization, the strongest determinant of inappropriateness was coronary anatomy. The odds ratio (OR) for inappropriate PTCA was 10.6 (95 per cent confidence interval (CI) 4.8-23.5) for the effect of left main stem or three-vessel disease versus single-vessel disease, and for CABG it was 0.06 (95 per cent CI 0.03-0.15). The number of diseased vessels was strongly related to preference for medical, PTCA or CABG treatment (p for linear trend <0.001). Mild versus severe anginal symptoms were associated with inappropriate angiography (OR 2.0 (95 per cent CI 0.9-9.8), although this effect was stronger when only the cardiologists' ratings were considered (OR 10.1 (95 per cent CI 2.4-42.6))., Conclusion: These are the first UK ratings of appropriateness covering all three procedures. The associations with clinical factors provide evidence of the internal consistency of these ratings. Prospective validation of these ratings against clinical outcomes is under way in the ACRE study.

Background: Elderly patients with ischaemic heart disease are often treated more conservatively and for longer than younger patients, but this strategy may result in subsequent invasive intervention of more advanced and higher risk coronary disease., Methods: We performed a retrospective analysis of 109 patients aged > or = 70 years (mean age 74 years, 66% men), who presented with angina refractory to maximal medical treatment or unstable angina over a 2-year period (1988-1990), to compare the relative risks and benefits of myocardial revascularisation [coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA)] in this higher-risk age group., Results: Sixty patients underwent CABG and 49 patients PTCA. There were eight periprocedural deaths in total (six in the CABG group, and two in the PTCA group, P = 0.29). Six patients in the CABG group suffered a cerebrovascular accident (two fatal). Acute Q-wave myocardial infarction occurred in one patient in the CABG group and in two patients in the PTCA group. The length of hospital stay was longer for the CABG group (CABG group 11.4 +/- 5.4 days, range 7-30 days, PTCA group 7.4 +/- 7.6 days, range 1-39 days, P = 0.01). Outcome was assessed using the major cardiac event rate (MACE; i.e. the rate of death, myocardial infarction, repeat CABG or PTCA). The cumulative event-free survival in the CABG group in 1, 2 and 3 years was 87, 85 and 85%, respectively. In contrast, in the PTCA group it was 55, 48 and 48% (P = 0.0001). Age, sex, number of diseased vessels, degree of revascularisation and left ventricular function were not predictive of the recurrence of angina in both groups. Actuarial survival (total mortality, including perioperative mortality) was lower at 1 year in the CABG group due to the higher perioperative mortality, but similar in both groups after the second year (P = 0.62)., Conclusions: Elderly patients with refractory or unstable angina who are revascularised surgically have a better long-term outcome (less frequent event rate of the composite end-point--myocardial infarction, revascularisation procedures and death) compared with those who are revascularised with PTCA. This benefit is been realised after the second year. Total mortality is similar in both groups after the second year. Therefore elderly patients who are fit for surgery should not be denied the benefits of CABG. PTCA may be regarded as a complementary and satisfactory treatment, especially for those whose life expectancy is limited to less than 2 years. The use of stents may improve outcome in the PTCA group and this needs to be evaluated.

Objective: To examine the short term results and long term survival of patients on long term dialysis undergoing coronary artery bypass graft surgery., Methods: A retrospective analysis of 19 patients on established dialysis who underwent coronary revascularisation between 1983 and 1995; 14 patients (73%) had class IV angina and five (25%) had unstable angina requiring heparin and nitrate infusions before surgery., Results: The 30 day mortality was 5%. Follow up was completed in the remaining 18 patients. The mean follow up time was 34 months (range eight to 61). During the follow up period four patients died of cardiac causes. The actuarial survival at one, two, and three years was 87%, 78%, and 59%, respectively. The overall functional status was significantly improved compared to preoperative levels, with a mean Karnofsky score of 76% (p < 0.01) at three years., Conclusions: Coronary artery bypass graft surgery can be performed with increased but acceptable morbidity and mortality in chronic dialysis patients. It results in considerable improvement in symptoms and functional status. However, long term survival is limited and this requires further investigation.

Objective: To assess the early results of combined coronary artery bypass graft surgery and carotid endarterectomy., Design: Retrospective and ongoing analysis of patients who underwent combined coronary artery bypass graft surgery and carotid endarterectomy., Setting: Cardiothoracic unit in a London teaching hospital., Patients: From June 1987 to March 1995, 64 patients were identified. They were patients who were scheduled to have coronary artery bypass graft surgery or required urgent coronary revascularisation and who were found to have significant coexistent carotid disease. (Unilateral carotid stenosis > 70%, bilateral carotid stenosis > 50%, or unilateral carotid stenosis > 50% with contralateral occlusion.), Interventions: Both procedures were performed during one anaesthesia: the carotid endarterectomy was performed first without cardiopulmonary bypass. After completion of carotid endarterectomy, coronary artery bypass graft surgery was performed., Main Outcome Measures: The incidence of stroke, transient ischaemic attack, and myocardial infarction in the early postoperative period was analysed., Results: Myocardial revascularisation was successful in all 64 patients. There were no perioperative infarcts. In three patients (4.7%) a new neurological deficit developed postoperatively: two recovered fully before hospital discharge., Conclusions: Combined coronary artery bypass graft surgery and carotid endarterectomy were performed safely and with good results.

The effects of radiation on the heart have been well described including acute and chronic pericarditis, myocardial fibrosis, accelerated arteriosclerosis of the coronary arteries. However, valvular dysfunction secondary to mediastinal irradiation has received less attention. We report two cases who developed valvular dysfunction associated with coronary artery disease possibly caused by mediastinal irradiation and a review of the literature regarding surgery for radiation induced valvular disease. Both patients underwent aortic valve replacement and coronary artery bypass graft surgery. With increasingly prolonged survival following mediastinal irradiation, we believe that long term follow up in patients who receive mediastinal irradiation is indicated.

This study was undertaken to identify the safety of outpatients awaiting coronary bypass surgery. An audit of the outcome of 92 such outpatients at one Regional centre was undertaken by a retrospective review of medical records. Outcome measures were: time on the waiting list, anti-ischaemic medications, readmission for unstable angina, myocardial infarction and death. Almost half of the patients underwent surgery within three months, and three-quarters waited less than six months. No outpatient death occurred. However, 4 of the 7 adverse events occurred within this period. Despite advanced disease, the safety of outpatients awaiting coronary surgery within such a short time frame appeared to be acceptable, the only adverse events being non-fatal and occurring unpredictably.

Despite the initial overall good results of aorto-coronary bypass grafting for myocardial revascularisation, a small but increasing number of patients require consideration for reoperation after the first procedure. In the period 1973 to 1981, 36 reoperations were performed in 34 patients with one operative death. In all of them the clinical indication for reoperation was recurrence of angina pectoris. In this special group of patients a high incidence of risk factors was present. Three major probable causes for the recurrence of angina were found: (1) Progression of the coronary atherosclerotic disease; (2) Graft failure; (3) Incomplete original revascularisation. Combined factors were present in 18 (53%) patients. There were no statistically significant differences in the incidence of postoperative complications at the first and second operation. Follow-up of 79% of the 33 survivors over a mean time period of 18 months, demonstrated no late mortality and a low subsequent infarction rate. Overall 69% of patients either lost their angina or were improved. We therefore conclude that reoperation can be accomplished with low mortality and morbidity and has a potential therapeutic benefit in the majority of cases.