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Sir,—Bathgate and Irving have wisely pointed out that the 10 year overall clinical results of coronary bypass can be disappointing.1 However, patients with severe class IV angina experienced pronounced symptom relief, allowing return to work in 91 of 100 consecutive bypassed cases, and an apparent improvement in survival with 88% alive a decade later.2
It seems that bypass is more beneficial in this group of more severely symptomatic patients, especially in those with advanced triple vessel or left main fixed disease when left ventricular function is impaired. Medical management alone generally will serve for those with milder symptoms and with less pronounced one, two or three vessel disease, while angioplasty is likely to be helpful in resistant patients.
This letter was shown to the authors, who reply as follows:
We agree with Dr Rogers that the greatest benefit of coronary bypass surgery is in those whose angina is particularly severe. However, our long term follow up indicated that no patient with impaired left ventricular function survived even five years. This is likely to be related to the different population studied. When advising patients about bypass surgery, it is important to use the results that are most pertinent rather than extrapolating from clinical trial data.
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