Bypass Angioplasty Revascularization Investigation (BARI)

BACKGROUND:

The management of patients with symptomatic coronary heart disease has evolved considerably in the past twenty years with the application of invasive techniques in an ever increasing proportion of patients.

With refinements in CABG surgery over the past twenty years, operative myocardial revascularization is feasible in most patients with myocardial ischemia. Several multicenter, randomized trials have been reported, comparing medical with surgical management in patients with coronary artery disease. Based on the three largest trials and an extensive observational literature, a consensus appears to be emerging regarding the circumstances under which medical or surgical management appears to be the method of choice.

It is clear that CABG relieves angina in the vast majority of patients with severe symptoms. It is also apparent that this procedure can be performed with very low risk by experienced operative teams. Thus, CABG is indicated for patients with suitable coronary anatomy who have severe angina refractory to medical therapy and those with significant obstruction of left main coronary artery.

The timing of operative intervention in patients with less severe angina is a point of some dispute at present. It is, however, apparent that certain categories of patients have improved survival after elective bypass surgery. These categories include patients with left main coronary stenosis, triple vessel disease with modestly impaired ventricular function, and possibly other clinically defined high risk patients. The remaining patients with mild, symptomatic coronary disease, it would appear, can afford to defer operative intervention until such time as symptoms worsen and require palliation.