Aortocoronary bypass grafting: an internist's perspective.

Abstract

Seven hundred fifty thousand to 1 million persons in this country have undergone aortocoronary bypass grafting since 1968, but many questions regarding the indications for the procedure and its advantages and disadvantages persist. Based on this surgical experience and on observations made during the last decade regarding nonoperative therapy and changes in the natural history of coronary heart disease, at least eight considerations should influence attitudes regarding the role of surgery: (1) The operation is a significant addition to the management of some patients with coronary heart disease. (2) The operative mortality in many centers is gratifyingly low. (3) Mortality from coronary heart disease in this country has declined strikingly during the past decade. (4) Because of the declining mortality from coronary heart disease, the prognosis of patients with the disease seen in 1980 is uncertain. (5) Coronary heart disease is a progressive disease and surgery does not prevent the progression of the disease in the native circulation. (6) Reports of therapeutic results, whether surgical or medical, are often biased toward the positive side. (7) Aortocoronary bypass does appear to postpone premature death in symptomatic patients with stenosis of the left main coronary artery, and possibly in symptomatic patients with three-vessel disease and modest impairment of left ventricular contractility. (8) Conclusions of meetings of "experts" regarding therapy may not by applicable to the country at large. The profession and the general public should be so informed.