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.