- Email: [email protected]
Importance of the internal mammary artery for coronary bypass grafting in patients aged ≥7O years
sound guide wbvdirected stent deployment. Am Heart J 1993;125:1213-1216. 12. Nakamura S, Colombo A. Gaghone A, Almagor Y, Goldberg SL, Maielo L. Finci L, Tobis JM. Intraxironary ultrasound observations during stent implantation. Circulation 1994;89:2026-2034. 13. La&y WK. Brady ST, Kussmaul WC, Waxier AR, Krol J. Henmann HC, Hb-shfeld SW Jr, Sebgal C. lntmvascular ulwsonographic assessment of the results of coronary artery scenting. Am Hear1 .I 1993; 125: 1576- 1.583. 14. Fiscbman DL. Savage MP, Leon MB, Schatz RA, Ellis SG, &man MW. Teirstein P, Walker CM, Bailey S, Hirshfeld JW, Goldberg S. Effect of intracoronary stenting on intimal dissection after balloon angioplasty: results of quantitative coronary analysis. JAm Cdl Cardioi 1991;18:1445-1451. 15. Henmann HC, Buchbinder M, Cleman MW. Fischman D, Goldberg S, Leon MB, Scbatz RA, T&-stein P, Walker CM, Hirshfeld JW. Emergent use of ballmnexpandable coronary ;utery stcnting for failed percutaneous transluminal coronary
luc Noyez,
MD, Tjeerd
Giliis
van der Werf, MD, Gerard H.J. Remmen, 1. Kaan, MD, and Leon K. Lacquet, MD
o doubt exists about the superiority of the internal mammary artery (IMA) as graft for myocardial revascularization. The relation between better long-term survival, freedom from reoperation, late cardiac events, and IMA use is well established.‘*2 Nevertheless, in elderly patients the decision to use IMA grafts for myocardial revascularization is still not settled.“,4 This prospective study compares the operative, postoperative, and 5-year results of coronary bypass grafting with the IMA in patients aged 270 years. .. . From January 1987 to December 1988, 100 patients aged 270 years (range 70 to 85 years, mean 74 & 3) underwent elective isolated coronary artery bypass grafting. Patients with ventriculotomies, valve replacement, cotibined procedures, and reoperations, and those with acute coronary disease (evolving infarction, ischemia not responding to medical therapy, cardiogenic shock including total mechanical dysfunction) were excluded. Based on patients’ date of birth, 2 groups were formed: IMA group (n = 57) in whom the IMA was used as graft, mostly in combination with venous grafts; non-I&IA group (n = 43) in whom only saphenous vein grafts were used. Only 1 patient (IMA group) had both internal mammary arteries grafted because there was no venous material available. The clinical profile of both groups and the frequency of coronary risk factors were not significantly different between the IMA and non-&IA groups (Table I). Obesity was defined as being overweight by >lO%, and diabetes mellitus was defined as having a positive glucose tolerance test, oral antidiabetic medication, or insulin dependency. Hypertension was defined as systolic blood pressure >160 mm Hg or diastolic pressure >lOO mm Hg. Hyperlipidemia was defined as a total cholesterol level >250 mg/dl or triglyceride levels >200 mg/dl. Pleuritis, asthma, previous pulmonary embolism, emphysema, obstructive disease, and previous lung operations were grouped as pulmonary problems.
#
Surgery
From the Deportments of ology of the Unlverslty 9 10 1, Geert Gtooteplein lands. Manuscri t received received kern & er 14,
Thoracic and Cardtoc and CardiHospital Nljmegen St. Rndboud, Pclstbus Zuid 10,6.500 HB Nijmegen, The NetherMarch 15, 1994; revised manuscript 1994, and accepted December 15.
734
JOURNAl
THE AMERICAN
angioplasty. Circulation 1992;86:812-8 19. 16. Maielo L, Colombo A. Gianrossi R, McCanny R, Finci L. Coronary stenting for lrttatment of acute or threatened closure following dissection after coronary angioplaaty. Am Heart J 1993;125:1570-1575. 17. Kiemeneij F. Laatman GJ, van der Wieken R, Suwarganda J. Emergency cownary stenting with the Palmaz-Schatz stent for failed transluminal coronary angioplaaty: results of a learning phase. Am Heart J 1993;126:23-31. 18. Haude M, E&e1 R. Iasa H, Straub U, Rupprccht HJ, Treese N, Meyer J. SUh acute tbrombotic complications after intracomnary implantation of Palmaz-Schatz stem. Am Hean J 1993; 126: 1Z-22. 19. Brown BG, Bolson E. Frimer M, Dodge HT. Quantitative coronary arteriography: estimation of diinsions, hemodynamic resistance, and atheroma mass of coronary artery lesions using the arteriogram and digital computation. Circulation 1977;55:329-337.
OF CARDIOLOGY”
VOL
75
MD,
All operations were performed under systemic hypothermia (25OC). Myocardial protection was ensured by intermittent anterograde infusion of cold, 4°C cardioplegia. In the IMA group the IMA was freed after opening the pleural cavity. To avoid the variability that would have arisen with multiple surgeons, all operations were performed by 1 surgeon, No significant difference could be found between the 2 groups as to the duration of the bypass (99 +, 12.7 vs 99 + 6.2 minutes), aortic cross-clamp time (53 f 4 vs 52 f 3.4 minutes), and the number of distal anastomoses (3.9 f 0.3 vs 3.9 f 0.3). Pre-, operative, and postoperative data were registered in the coronary databank Coronary Surgery DatabaseRadboud Hospital (CORRAD), and follow-up data were collected from cardiologists, general practitioners, and telephone interviews with patients or family. Data were analyzed with the Student’s t test, chi-square, or Wilcoxon test when appropriate. Survival probabilities and standard errors were estimated by the actuarial method.5 Postoperatively, no statistical significant difference could be demonstrated between the 2 groups. Low cardiac output was noted when there was a need for positive inotropic support (9 pg/kg/min) of dopamine for TAME
I Preoperative
Data Group IMA (n = 57)
28/29 70-85
Men/women
Age Irange,
yr)
Obesity
10 (18)
7 (12)
Diabetes mellitus Hypertension Hyperlipidemia Peripheral vascular arterial Pulmonary problems Prior myocardial infarction NYHA class 111 NYHA class IV Ejection fraction ~35% Left main stenosis 3-vessel coronary IMA 4 internal
APRIL
1, 1995
(%)
disease
12 (21) 32 (56) 35 (61) 22
artery;
(39)
2 (4) 8 (141 43 1751
narrowing mommory
18 (32) 18 (32) 12 (21)
NYHA
= New York Heart
Non-IMA (n = 43)
(%)
26/17 70-83 9 (211 4 (9) 20 (47) 18 (42) 11 (261 11 (26) 28 (65) 25 (58) 18 (42) 1 12) 5 (12) 35 1811 Association.
212 hours): 4 patients in the IMA (7%), 6 in the non- free actuarial 5-year survival showed freedom from carIMA (14%) group, Myocardial infarction was defined as disc events in 85 + 0.12% of the IMA patients versus 61 new postoperative Q wave or T-wave changes accom- f 0.22% for the non-IMA patients (p ~0.05) (Figure 4). . .. panied by increased cardiac enzymes: 1 patient in the This study shows that the use of the IMA graft in IMA (1.7%), 2 in the non-WA (4%) group. Pneumonia, atelectasis for ~2 days, pleural effusion needing drain- elderly patients results in a better functional class, lesser risk of cardiac events, and improved 5-year survival. age, and pneumothorax were grouped under pulmonary problems: 6 patients in the IMA (ll%), 5 in the non-IMA (12%) group. Three percent of patients patients in the IMA (5.3%) and 4 in the __~~~ 100 non-IMA (9.3%) group required ventilation for >24 hours. The only patient (IMA group) with wound problems was an obese 80 !Lvo.05 woman with a superficial wound necrosis. I Causes of death in the 2 patients (1 in each 60 group) were myocardial infarction and low cardiac output. Follow-up of the 98 hospital survivors 40 was 98.9% complete. One patient (nonIMA group) was lost to follow-up (mean 20 duration of follow-up 67.4 + 4 months [range 61 to 771). Significant postoperative improvement NYHA I NYHA II NYHA Ill NYHA IV in symptomatology was found in both groups; however, significantly more paFIGURE I. Postoperah New Yodc Heart Association (NYHA) functional classifitients in the IMA than in the non-&IA cation. IMA = internal mammary artery. group (36 of 56 vs 15 of 41) returned to New York Heart Association class I (Fig1 ure 1). This improvement was confirmed of patients .^^ percent 1uu by patients’ subjective evaluation of their life situation according to the question: Are IMA non-HA you feeling better, worse, or is there no 60 improvement since the cardiac operation? (Figure 2). Also, the need for cardiac med60 ications (p blockers, calcium entry blockers, and nitrates) decreased in 68% of the IMA (38 of 56) and in 49% of the non40 IMA (20 of 41) patients (p 4.05). During follow-up, a cardiac event, de20 fined as a documented myocardial infarction, new arrhythmia, return of angina, or 0 cardiac death, was noted in 9 of 56 pabetter no improvement worse tients in the IMA group and in 14 of 40 patients in the non-IMA group. This dif- FIGURE 2. Patient evahiun of life situation 5 years after operation. IMA = ference was statistically significant (p internal mammary shy.
735
percent ‘;I[
survival kZ<
85%
:: -;
‘-------
60
61%
: PcO.05
20 0 .~ ~-.. .._. -L-----.1 l/l2
_... -d-.
IMA
-
-+ / 4
ity of life. Our study shows that the need fir cardiac medication and the patients’ self-evaluation of their quality of life are related to IMA use. Based on our results, it is cokluded that the use of the IMA graft in elderly patients does not result in increased postoperative morbidity and mortality; the IMA graft results in a better S-year survival, less medication, and an improved quality of life.
non-IMA .-
1. Loop FD. Lytle BW, Cosgrwe DM, Stewart EW. Goormastic M, Williams GW, Gelding LA, Gill GC, Taylor PC, years Sheldon WC, Proudfit WL. Influence of the internal manmary artery graft on IO-years survival and other cardiac events. N Engl J Med 1986;314:1-6. FIGURE 4. Ever&m ochmriai survivui by group. IMA = inked mammary arhy. 2. Acinapura AJ, Rose DM, Jacobowitz 11. Internal mamma‘y artery bypas grafting: iofluence on recurrent angina and These results are in agreement with the study of Gard- survival in 2,100 patients. Ann Thorar Surg 1989:48:186-191. 3. Rich MW, Keller AI, Schechtman KB, Marshall WG Jr, Kouchoukos NT. Morner et al,‘j who showed that IMA use in the elderly did bxiity and mortality of coronary bypass surgery in patients 75 years of age or oldnot result in more surgical complications, and a signifi- er. Ann Thoruc Sury: 1988;46:638+44. Olearchyk AS, Magovern GJ. Internal mammaw artery eraftine: clinical results. cantly better survival rate was seen at 4 years in patients 4.patency rates, and long-term survival in 833 patients. I Thorack~dicrvasr Surx receiving IMA grafts than that seen in patients who only 1986:92:1082-1087. received venous grafts (87% vs 77%, respectively). 5. Anderson RP. Bonchak Li. Grunkemeier GL, Lambert LE. Starr A. The analysis and presentation of surgical results by actuarial methods. .I Surg RPS 1974: Azariades and co-workers7 also described a significant16:224-230. ly higher 5-year survival and a better improvement in 6. Gardner TJ, Greene PS, Rykiel MF, Baumgarmer WA, Cameron DE, &sale functional class in patients with an IMA graft. Howev- AS, Gott VL, Watkins L, Reits BA. Routine use of the left internal mammary anery graft in the elderly. Ann Thorac Surfi 199@49:188-194. er, both studies were not randomized. 7. Azariades M, Fessler CL, Floten HS. Stan A. Five-year results ofcoronary bypass In patients aged 270 years, evaluation of the opera- grafting for patients older than 70 years: role of the internal mammary artery. Ann tion should focus less on survival and more on the qual- Thoroc Surjj 1990:50:94&945.
1
3 2 postoperative
5
_
Dive ent Reporting B z re Corenary Michael
_L
of Coronary Risk Factem Awbry Bypass Surgery
Miller, DM, Karen Konkel, DM, David Fitzpatrick, Rachel Burgan, and Robert A. Vogel, D&l
DM,
between January and June 1992. Patients were initially admitted to either the medical (n = 92) or surgical (n = presence of traditional coronary risk factors has been 166) service. Forty-nine percent of medical admissions shown to itiuence the development and severity of is- and 80% of surgical admissions were elective. The demchemic heart disease.2 Limited information is available ographics included 180 men and 78 women; there were regarding the extent to which coronary risk factors are 216 Caucasians, 39 African-Americans, and 3 Asiandetailed by the admitting house officer. Because coro- Indians. nary artery disease (CAD) is the most common cause of The admission history in each patient was reviewed death in the United States, we hypothesized that detailed using a questionnaire designed to evaluate the extent to information on coronary risk factors would be readily which coronary risk factors were recorded by medical available from the admission history in patients admitor surgical house staff. Responses included “yes,” “no,” ted with CAD before coronary artery bypass grafting. or information “not available.” For example, if pertinent ..* negatives were not recorded by the house officer (e.g., We reviewed the medical records of 258 consecutive no history of diabetes mellitus) the response was classpatients who had coronary artery bypass grafting per- ified as “not available.” The variables included in the formed at the University of Maryland Medical Center questionnaire were systemic hypertension, cigarette smoking, diabetes melhtus, premature menopause, family history of premature CAD (~5.5 years of age in a firstFrom the Dlvlsion of Cardiology, The Universh/ of Maryland Meddegree relative) and hyperlipidemia. Laboratory tests perical System, Baltimore, Maryland 21201. This research was sup formed on admission were also recorded. They included ported by a National lnstltutes of Health-Preventive Cardiology Acacomplete blood counts, blood urea nitrogen, creatinine, demic Award (K07-Hl-0226303). Manuscript recetved September 29, 1994, revised manuscript received and accepted December 7, glucose, thyroid-stimulating hormone, and a fasting lipid 1994. profile. he medical history remains an invaluable tool for
T assessing cardiovascular disease.’ In this regard, the
736
THE AMERICAN
JOURNAl
OF CARDIOIOGY”
VOL
75
APRIL
1, 1995
luc Noyez,
MD, Tjeerd
Giliis
van der Werf, MD, Gerard H.J. Remmen, 1. Kaan, MD, and Leon K. Lacquet, MD
o doubt exists about the superiority of the internal mammary artery (IMA) as graft for myocardial revascularization. The relation between better long-term survival, freedom from reoperation, late cardiac events, and IMA use is well established.‘*2 Nevertheless, in elderly patients the decision to use IMA grafts for myocardial revascularization is still not settled.“,4 This prospective study compares the operative, postoperative, and 5-year results of coronary bypass grafting with the IMA in patients aged 270 years. .. . From January 1987 to December 1988, 100 patients aged 270 years (range 70 to 85 years, mean 74 & 3) underwent elective isolated coronary artery bypass grafting. Patients with ventriculotomies, valve replacement, cotibined procedures, and reoperations, and those with acute coronary disease (evolving infarction, ischemia not responding to medical therapy, cardiogenic shock including total mechanical dysfunction) were excluded. Based on patients’ date of birth, 2 groups were formed: IMA group (n = 57) in whom the IMA was used as graft, mostly in combination with venous grafts; non-I&IA group (n = 43) in whom only saphenous vein grafts were used. Only 1 patient (IMA group) had both internal mammary arteries grafted because there was no venous material available. The clinical profile of both groups and the frequency of coronary risk factors were not significantly different between the IMA and non-&IA groups (Table I). Obesity was defined as being overweight by >lO%, and diabetes mellitus was defined as having a positive glucose tolerance test, oral antidiabetic medication, or insulin dependency. Hypertension was defined as systolic blood pressure >160 mm Hg or diastolic pressure >lOO mm Hg. Hyperlipidemia was defined as a total cholesterol level >250 mg/dl or triglyceride levels >200 mg/dl. Pleuritis, asthma, previous pulmonary embolism, emphysema, obstructive disease, and previous lung operations were grouped as pulmonary problems.
#
Surgery
From the Deportments of ology of the Unlverslty 9 10 1, Geert Gtooteplein lands. Manuscri t received received kern & er 14,
Thoracic and Cardtoc and CardiHospital Nljmegen St. Rndboud, Pclstbus Zuid 10,6.500 HB Nijmegen, The NetherMarch 15, 1994; revised manuscript 1994, and accepted December 15.
734
JOURNAl
THE AMERICAN
angioplasty. Circulation 1992;86:812-8 19. 16. Maielo L, Colombo A. Gianrossi R, McCanny R, Finci L. Coronary stenting for lrttatment of acute or threatened closure following dissection after coronary angioplaaty. Am Heart J 1993;125:1570-1575. 17. Kiemeneij F. Laatman GJ, van der Wieken R, Suwarganda J. Emergency cownary stenting with the Palmaz-Schatz stent for failed transluminal coronary angioplaaty: results of a learning phase. Am Heart J 1993;126:23-31. 18. Haude M, E&e1 R. Iasa H, Straub U, Rupprccht HJ, Treese N, Meyer J. SUh acute tbrombotic complications after intracomnary implantation of Palmaz-Schatz stem. Am Hean J 1993; 126: 1Z-22. 19. Brown BG, Bolson E. Frimer M, Dodge HT. Quantitative coronary arteriography: estimation of diinsions, hemodynamic resistance, and atheroma mass of coronary artery lesions using the arteriogram and digital computation. Circulation 1977;55:329-337.
OF CARDIOLOGY”
VOL
75
MD,
All operations were performed under systemic hypothermia (25OC). Myocardial protection was ensured by intermittent anterograde infusion of cold, 4°C cardioplegia. In the IMA group the IMA was freed after opening the pleural cavity. To avoid the variability that would have arisen with multiple surgeons, all operations were performed by 1 surgeon, No significant difference could be found between the 2 groups as to the duration of the bypass (99 +, 12.7 vs 99 + 6.2 minutes), aortic cross-clamp time (53 f 4 vs 52 f 3.4 minutes), and the number of distal anastomoses (3.9 f 0.3 vs 3.9 f 0.3). Pre-, operative, and postoperative data were registered in the coronary databank Coronary Surgery DatabaseRadboud Hospital (CORRAD), and follow-up data were collected from cardiologists, general practitioners, and telephone interviews with patients or family. Data were analyzed with the Student’s t test, chi-square, or Wilcoxon test when appropriate. Survival probabilities and standard errors were estimated by the actuarial method.5 Postoperatively, no statistical significant difference could be demonstrated between the 2 groups. Low cardiac output was noted when there was a need for positive inotropic support (9 pg/kg/min) of dopamine for TAME
I Preoperative
Data Group IMA (n = 57)
28/29 70-85
Men/women
Age Irange,
yr)
Obesity
10 (18)
7 (12)
Diabetes mellitus Hypertension Hyperlipidemia Peripheral vascular arterial Pulmonary problems Prior myocardial infarction NYHA class 111 NYHA class IV Ejection fraction ~35% Left main stenosis 3-vessel coronary IMA 4 internal
APRIL
1, 1995
(%)
disease
12 (21) 32 (56) 35 (61) 22
artery;
(39)
2 (4) 8 (141 43 1751
narrowing mommory
18 (32) 18 (32) 12 (21)
NYHA
= New York Heart
Non-IMA (n = 43)
(%)
26/17 70-83 9 (211 4 (9) 20 (47) 18 (42) 11 (261 11 (26) 28 (65) 25 (58) 18 (42) 1 12) 5 (12) 35 1811 Association.
212 hours): 4 patients in the IMA (7%), 6 in the non- free actuarial 5-year survival showed freedom from carIMA (14%) group, Myocardial infarction was defined as disc events in 85 + 0.12% of the IMA patients versus 61 new postoperative Q wave or T-wave changes accom- f 0.22% for the non-IMA patients (p ~0.05) (Figure 4). . .. panied by increased cardiac enzymes: 1 patient in the This study shows that the use of the IMA graft in IMA (1.7%), 2 in the non-WA (4%) group. Pneumonia, atelectasis for ~2 days, pleural effusion needing drain- elderly patients results in a better functional class, lesser risk of cardiac events, and improved 5-year survival. age, and pneumothorax were grouped under pulmonary problems: 6 patients in the IMA (ll%), 5 in the non-IMA (12%) group. Three percent of patients patients in the IMA (5.3%) and 4 in the __~~~ 100 non-IMA (9.3%) group required ventilation for >24 hours. The only patient (IMA group) with wound problems was an obese 80 !Lvo.05 woman with a superficial wound necrosis. I Causes of death in the 2 patients (1 in each 60 group) were myocardial infarction and low cardiac output. Follow-up of the 98 hospital survivors 40 was 98.9% complete. One patient (nonIMA group) was lost to follow-up (mean 20 duration of follow-up 67.4 + 4 months [range 61 to 771). Significant postoperative improvement NYHA I NYHA II NYHA Ill NYHA IV in symptomatology was found in both groups; however, significantly more paFIGURE I. Postoperah New Yodc Heart Association (NYHA) functional classifitients in the IMA than in the non-&IA cation. IMA = internal mammary artery. group (36 of 56 vs 15 of 41) returned to New York Heart Association class I (Fig1 ure 1). This improvement was confirmed of patients .^^ percent 1uu by patients’ subjective evaluation of their life situation according to the question: Are IMA non-HA you feeling better, worse, or is there no 60 improvement since the cardiac operation? (Figure 2). Also, the need for cardiac med60 ications (p blockers, calcium entry blockers, and nitrates) decreased in 68% of the IMA (38 of 56) and in 49% of the non40 IMA (20 of 41) patients (p 4.05). During follow-up, a cardiac event, de20 fined as a documented myocardial infarction, new arrhythmia, return of angina, or 0 cardiac death, was noted in 9 of 56 pabetter no improvement worse tients in the IMA group and in 14 of 40 patients in the non-IMA group. This dif- FIGURE 2. Patient evahiun of life situation 5 years after operation. IMA = ference was statistically significant (p internal mammary shy.
735
percent ‘;I[
survival kZ<
85%
:: -;
‘-------
60
61%
: PcO.05
20 0 .~ ~-.. .._. -L-----.1 l/l2
_... -d-.
IMA
-
-+ / 4
ity of life. Our study shows that the need fir cardiac medication and the patients’ self-evaluation of their quality of life are related to IMA use. Based on our results, it is cokluded that the use of the IMA graft in elderly patients does not result in increased postoperative morbidity and mortality; the IMA graft results in a better S-year survival, less medication, and an improved quality of life.
non-IMA .-
1. Loop FD. Lytle BW, Cosgrwe DM, Stewart EW. Goormastic M, Williams GW, Gelding LA, Gill GC, Taylor PC, years Sheldon WC, Proudfit WL. Influence of the internal manmary artery graft on IO-years survival and other cardiac events. N Engl J Med 1986;314:1-6. FIGURE 4. Ever&m ochmriai survivui by group. IMA = inked mammary arhy. 2. Acinapura AJ, Rose DM, Jacobowitz 11. Internal mamma‘y artery bypas grafting: iofluence on recurrent angina and These results are in agreement with the study of Gard- survival in 2,100 patients. Ann Thorar Surg 1989:48:186-191. 3. Rich MW, Keller AI, Schechtman KB, Marshall WG Jr, Kouchoukos NT. Morner et al,‘j who showed that IMA use in the elderly did bxiity and mortality of coronary bypass surgery in patients 75 years of age or oldnot result in more surgical complications, and a signifi- er. Ann Thoruc Sury: 1988;46:638+44. Olearchyk AS, Magovern GJ. Internal mammaw artery eraftine: clinical results. cantly better survival rate was seen at 4 years in patients 4.patency rates, and long-term survival in 833 patients. I Thorack~dicrvasr Surx receiving IMA grafts than that seen in patients who only 1986:92:1082-1087. received venous grafts (87% vs 77%, respectively). 5. Anderson RP. Bonchak Li. Grunkemeier GL, Lambert LE. Starr A. The analysis and presentation of surgical results by actuarial methods. .I Surg RPS 1974: Azariades and co-workers7 also described a significant16:224-230. ly higher 5-year survival and a better improvement in 6. Gardner TJ, Greene PS, Rykiel MF, Baumgarmer WA, Cameron DE, &sale functional class in patients with an IMA graft. Howev- AS, Gott VL, Watkins L, Reits BA. Routine use of the left internal mammary anery graft in the elderly. Ann Thorac Surfi 199@49:188-194. er, both studies were not randomized. 7. Azariades M, Fessler CL, Floten HS. Stan A. Five-year results ofcoronary bypass In patients aged 270 years, evaluation of the opera- grafting for patients older than 70 years: role of the internal mammary artery. Ann tion should focus less on survival and more on the qual- Thoroc Surjj 1990:50:94&945.
1
3 2 postoperative
5
_
Dive ent Reporting B z re Corenary Michael
_L
of Coronary Risk Factem Awbry Bypass Surgery
Miller, DM, Karen Konkel, DM, David Fitzpatrick, Rachel Burgan, and Robert A. Vogel, D&l
DM,
between January and June 1992. Patients were initially admitted to either the medical (n = 92) or surgical (n = presence of traditional coronary risk factors has been 166) service. Forty-nine percent of medical admissions shown to itiuence the development and severity of is- and 80% of surgical admissions were elective. The demchemic heart disease.2 Limited information is available ographics included 180 men and 78 women; there were regarding the extent to which coronary risk factors are 216 Caucasians, 39 African-Americans, and 3 Asiandetailed by the admitting house officer. Because coro- Indians. nary artery disease (CAD) is the most common cause of The admission history in each patient was reviewed death in the United States, we hypothesized that detailed using a questionnaire designed to evaluate the extent to information on coronary risk factors would be readily which coronary risk factors were recorded by medical available from the admission history in patients admitor surgical house staff. Responses included “yes,” “no,” ted with CAD before coronary artery bypass grafting. or information “not available.” For example, if pertinent ..* negatives were not recorded by the house officer (e.g., We reviewed the medical records of 258 consecutive no history of diabetes mellitus) the response was classpatients who had coronary artery bypass grafting per- ified as “not available.” The variables included in the formed at the University of Maryland Medical Center questionnaire were systemic hypertension, cigarette smoking, diabetes melhtus, premature menopause, family history of premature CAD (~5.5 years of age in a firstFrom the Dlvlsion of Cardiology, The Universh/ of Maryland Meddegree relative) and hyperlipidemia. Laboratory tests perical System, Baltimore, Maryland 21201. This research was sup formed on admission were also recorded. They included ported by a National lnstltutes of Health-Preventive Cardiology Acacomplete blood counts, blood urea nitrogen, creatinine, demic Award (K07-Hl-0226303). Manuscript recetved September 29, 1994, revised manuscript received and accepted December 7, glucose, thyroid-stimulating hormone, and a fasting lipid 1994. profile. he medical history remains an invaluable tool for
T assessing cardiovascular disease.’ In this regard, the
736
THE AMERICAN
JOURNAl
OF CARDIOIOGY”
VOL
75
APRIL
1, 1995