Medical compared with surgical management of XXXX . 5-year mortality and morbidity in the Veterans Administration Study.

@entity1 @entity1459 @entity951 @entity66
We evaluated medical in comparison to surgical plus medical (surgical) treatment of @entity1459 using a prospective randomized protocol that stratified @entity1 by clinical presentation and by invasive evaluation of left ventricular (LV) function. Clinical presentations were as follows--type 1: progressive or new onset @entity951 relieved by medication; type 2: prolonged bouts of @entity951 poorly or incompletely relieved by medication. Abnormal LV function was arbitrarily defined as ejection fraction less than 0.50 or LV end-diastolic pressure 16 mm Hg or more. Of 468 @entity1 , 237 were assigned to medical and 231 to surgical therapy. There were 374 type 1 and 94 type 2 @entity1 . LV function was normal in 334 and abnormal in 134 @entity1 . Compared with results at 24 months, this 60-month follow-up study showed important differences in survival for @entity1 with @entity66 : 75% for medical and 89% for surgical @entity1 (p less than 0.02). The cumulative 5-year rate of repeat hospitalizations for cardiac reasons was less with surgical @entity1 for either clinical presentation. For type 1, medical @entity1 had a 56% rate, and surgical @entity1 had a 42% rate (p = 0.004). For type 2, medical @entity1 had a 62% rate, and surgical @entity1 had a 43% rate (p = 0.05). Overall mortality did not differ between the two treatments, and this remained true in type 1 versus type 2 @entity1 and in those with normal versus abnormal LV function. However, regression analysis of medical and surgical groups with ejection fraction as a continuous variable showed that mortality of medical @entity1 depended on ejection fraction (p = 0.004), whereas the mortality of surgical @entity1 did not (p = 0.76), and survival in the surgical group was higher in the lowest ejection fraction tercile-73% for medical and 86% for surgical @entity1 , p = 0.03. We conclude that surgery improves survival in @entity1 with @entity66 and leads to fewer subsequent hospitalizations for cardiac reasons. An impaired ejection fraction had an adverse impact on survival of medical @entity1 but not on surgical @entity1 , and mortality in surgical @entity1 was improved compared with medical @entity1 in the lowest ejection fraction tercile.
