Unstable angina. Quality of life.

C oronary artery disease continues to be the leading cause of death in the United States despite an encouraging 48% reduction in age-adjusted mortality since the epidemic peaked in 1963.1 Coronary artery disease results in approximately 500,000 deaths each year with about 750,000 hospital admissions for acute myocardial infarction and probably an equal number of admissions for unstable angina. Unstable angina can be the harbinger of acute myocardial infarc-tion and sudden death. It likely has a similar coronary pathophysiology of plaque rupture and coronary thrombus formation. Interrupting the process and stabilizing the lesion may be possible with medication alone in many patients. Angioplasty and bypass surgery are important additional therapies should medical therapy fail to control symptoms. This issue of Circulation includes a paper by Booth et a12 comparing various indexes of quality of life in patients with unstable angina randomized to a strategy of coronary artery bypass graft surgery with those of a group assigned to a nonsurgical strategy and followed for 5 years. The Veterans Cooperative Studies Program has supported randomized trials of coronary bypass surgery in both chronic stable angina34 and in unstable angina5-7; these studies have made major contributions to the development of indications for the use of bypass surgery. The European Coronary Surgery Study8 and two studies supported by the National Heart, Lung, and Blood Institute9-11 have also made contributions to this effort.7-10 The Veterans Administration Cooperative Study carried out by Booth et a12 includes 468 patients with See p 87 either progressive/new onset angina (Type I, 374 patients) or prolonged angina at rest (Type II, 94 patients) equivalent to class IB and class IIB/IIIB, respectively, in Braunwald's recently proposed classification scheme.12 Randomization created groups well balanced for recognized prognostically important baseline characteristics (and presumably for unrecognized factors as well). Operative mortality in those The opinions expressed in this editorial comment are not necessarily those of the editors or of the American Heart Association. assigned to surgery was 4.1%. Analysis of 1-year graft patency determined on 67% of surgically assigned patients revealed that approximately 55% of these patients had all grafts patent and approximately 90% had at least one patent graft. By 60 months 43% of patients assigned to the nonsurgical strategy had undergone bypass; three fourths of these patients had undergone bypass during the first 18 months. Five-year mortality follow-up is complete and reveals no survival difference overall. A survival advantage in surgically assigned …