Coronary Artery Surgery Study Registry Research Articles

Dilated Psoriatic Coronopathy: A Novel Association

Coronary artery ectasia (CAE) is defined by the Coronary Artery Surgery Study (CASS)registry as the aneurysmal dilatation 1.5 times the diameter of a coronary artery compared to the adjacent normal coronary artery. CAE is reported with a prevalence of 1.2% - 4.9%. Most CAEs are attributed to atherosclerosis or post-percutaneous coronary intervention (PCI) vessel injury. Vasculitides and infection are uncommon etiologies. A review of 59,423 patients from the Danish registry demonstrated a 3-fold increase in the prevalence of abdominal aortic aneurysms in patients with concomitant severe psoriasis. We present a case of a 64-year-old male with severe plaque psoriasis complaining of substernal chest pain whose coronary angiography demonstrated CAE of the left anterior descending and circumflex arteries. Due to its pro-inflammatory state, psoriasis is associated with various systemic manifestations including cardiac and vascular complications. With possibly a similar underlying pathophysiological mechanism, we describe to the best of our knowledge the first case of CAE in a patient with severe psoriasis.

Interventions for Left Main Coronary Artery Disease

Unprotected left main coronary artery (ULMCA) disease constitutes 5 to 7% of the patients undergoing coronary angiography.[1] It is associated with a high mortality as it supplies a large area of the myocardium—approximately 84% of the left ventricle in right dominant system and 100% in a left dominant system.[2] In CASS (Coronary Artery Surgery Study) registry, mortality in medically treated patients is as high as 63% at 5 years.[3]

50th Anniversary Landmark Commentary on Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: The Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 1994;57:12–9

50th Anniversary Landmark Commentary on Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: The Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 1994;57:12–9

Young coronary artery disease in patients undergoing percutaneous coronary intervention

BACKGROUND AND OBJECTIVESUnderstanding the nature and pattern of young coronary artery disease (CAD) is important due to the tremendous impact on these patients’ socio-economic and physical aspect. Data on young CAD in the southeast Asian region is rather patchy and limited. Hence we utilized our National Cardiovascular Disease Database (NCVD)—Percutaneous Coronary Intervention (PCI) Registry to analyze young patients who underwent PCI in the year 2007 to 2009.DESIGN AND SETTINGSThis is a retrospective study of all patients who had undergone coronary angioplasty from 2007 to 2009 in 11 hospitals across Malaysia.METHODSData were obtained from the NCVD—PCI Registry, 2007 to 2009. Patients were categorized into 2 groups—young and old, where young was defined as less than 45 years for men and less than 55 years for women and old was defined as more than or equals to 45 years for men and more than or equals to 55 years for women. Patients’ baseline characteristics, risk factor profile, extent of coronary disease and outcome on discharge, and 30-day and 1-year follow-up were compared between the 2 groups.RESULTSWe analyzed 10 268 patients, and the prevalence of young CAD was 16% (1595 patients). There was a significantly low prevalence of Chinese patients compared to other major ethnic groups. Active smoking (30.2% vs 17.7%) and obesity (20.9% vs 17.3%) were the 2 risk factors more associated with young CAD. There is a preponderance toward single vessel disease in the young CAD group, and they had a favorable clinical outcome in terms of all-cause mortality at discharge (RR 0.49 [CI 0.26–0.94]) and 1-year follow-up (RR 0.47 [CI 0.19–1.15]).CONCLUSIONWe observed distinctive features of young CAD that would serve as a framework in the primary and secondary prevention of the early onset CAD.

Heart Rate Recovery After Exercise and Long-term Prognosis in Patients With Coronary Artery Disease

BackgroundThe long-term prognostic value of heart rate recovery (HRR) has been incompletely documented in patients with coronary artery disease (CAD). We sought to confirm the prognostic value of HRR in a large cohort with stable CAD. MethodsFrom the Coronary Artery Surgery Study registry, a database of 24,958 patients with CAD who underwent cardiac catheterization between 1974 and 1979, we identified 4097 patients with baseline exercise stress testing data. HRR was measured at 3 minutes post exercise during a passive recovery. Clinical outcomes were evaluated according to HRR in both threshold and continuous models. ResultsMedian long-term follow-up was 14.7 years (interquartile range, 9.8-16.2). HRR < 46 beats per minute (Bpm) most appropriately differentiated nonsurvivors from survivors (area under receiver operating characteristic curve = 0.613) and was associated with an increased risk of all-cause death (adjusted hazard ratio = 1.15; P = 0.011). Increasing HRR was associated with a lower risk of all-cause (adjusted hazard ratio = 0.94 per 10 Bpm; 95% confidence interval, 0.91-0.97; P = 0.0005) and cardiovascular (CV) mortality (adjusted hazard ratio = 0.94 per 10 Bpm; 95% confidence interval, 0.90-0.98; P = 0.003). ConclusionsHRR at 3 minutes independently predicts long-term all-cause and CV mortality in patients with stable CAD. Measurement of HRR at 3 minutes during passive recovery can be used as a complementary tool to identify patients with a higher total and CV risk.

Effects of fasting and/or postprandial glucose on heart rate recovery in patients with coronary heart disease

The impact of both fasting and postprandial glycaemia on heart rate recovery (HRR) has not been studied in patients with coronary heart disease (CHD). For this reason, we sought to determine the relationships between HRR and both fasting and postprandial glycaemia. A total of 4079 patients with baseline fasting plasma glucose (FPG) levels and 706 patients with 2-hour postprandial glucose (2hPG) levels were identified from the Coronary Artery Surgery Study registry, a database of 24,958 patients with suspected or proven CHD who had undergone cardiac catheterization between 1974 and 1979. Median long-term follow-up was 14.7 years (interquartile range: 9.8-16.2 years). The relationships between HRR and both FPG and 2hPG were studied. In univariate analyses, increasing levels of both FPG and 2hPG were significantly associated with lower HRR. In multivariate models adjusted for age, exercise tolerance in METs, resting heart rate and maximum systolic blood pressure during exercise testing, FPG remained significantly associated with HRR while 2hPG did not. Both raised FPG and decreased HRR are independent predictors of total and cardiovascular (CV) mortality in subjects with CHD. Our data suggest that the mortality risk associated with elevated FPG may in part be due to deleterious effects on autonomic regulation of CV function, as reflected by lower HRR. Further studies are required to determine whether or not non-pharmacological and/or pharmacological treatments of increased fasting glucose have a beneficial influence on HRR.

The pivotal role of heart rate in clinical practice: from atherosclerosis to acute coronary syndrome

Heart rate is a predictor of major cardiovascular events in both the general population and patients with various cardiovascular diseases. The association between resting heart rate and mortality has been observed in patients with hypertension and with metabolic syndrome and in the elderly. The prognostic value of heart rate has also been shown in patients with stable coronary heart disease. We assessed the relationship between resting heart rate at baseline and cardiovascular mortality and morbidity, while adjusting for risk factors. A total of 24 913 patients with suspected or proven coronary artery disease from the Coronary Artery Surgery Study registry were studied for a median follow-up of close to 15 years. All-cause and cardiovascular mortality and cardiovascular re-hospitalizations were increased with increasing heart rate (P , 0.0001). When compared with the reference group, patients with resting heart rate � 83 bpm at baseline had a significantly higher risk for total mortality [hazard ratio 1.32; confidence interval (CI) 1.19–1.47; P , 0.0001] and cardiovascular mortality (hazard ratio 1.31; CI 1.15–1.48; P , 0.0001) after adjustment for multiple clinical variables. When comparing patients with heart rates between 77–82 and � 83 bpm with patients with a heart rate � 62 bpm, the hazard ratios for time to first cardiovascular re-hospitalization were 1.11 and 1.14 (P , 0.001 for both). Resting heart rate has also been shown to be associated with the severity and rate of progression of coronary atherosclerosis and to be an independent predictor of plaque rupture in coronary arteries. Resting heart rate is a simple measurement with prognostic implications.

Should All Patients With Asymptomatic but Significant (&gt;50%) Left Main Coronary Artery Stenosis Undergo Surgical Revascularization?

The incidental detection of asymptomatic but significant (>50%) left main coronary artery disease (LMCAD) has become more frequent with the increased use of coronary angiography for acute myocardial infarction. Most would agree that such LMCAD cannot be ignored. Yet, clarity is somewhat lacking as to the best approach to managing such patients. The long-running debate of the best revascularization method of LMCAD has flared up again. However, medical management also may be a viable option for some of these patients. A 64-year-old nondiabetic man without a history of cardiovascular disease is admitted with an acute inferior ST-elevation myocardial infarction. He undergoes successful primary angioplasty of a dominant right coronary artery. Left ventriculography reveals inferior hypokinesis with an estimated ejection fraction of 45% to 50%. However, the patient also has a smooth mid-to-distal 60% LMCAD without any significant lesions in the left anterior descending or left circumflex artery. A month later, a stress echocardiogram reveals no new wall motion abnormalities. On the basis of this presentation, should he be referred for coronary artery bypass graft (CABG) surgery? The American College of Cardiology/American Heart Association (ACC/AHA) 2002 guidelines for stable angina1 discuss the indications for CABG surgery separately for symptomatic and asymptomatic LMCAD, but the recommendations are the same for both: Revascularization with CABG is a class I recommendation with level of evidence B. (Class I recommendations indicate situations for which evidence or general agreement exists that a given procedure or treatment is beneficial, useful, and effective.) An abbreviated version of these same guidelines was published in 2003.2 These guidelines acknowledged that the evidence behind the recommendation for asymptomatic patients is weak, yet the class IB recommendation was not changed. The ACC/AHA 2004 guidelines for use of CABG surgery also separate symptomatic and asymptomatic LMCAD recommendations and propose that CABG …

Usefulness of Self-Reported Leisure-Time Physical Activity to Predict Long-Term Survival in Patients With Coronary Heart Disease

Self-reported leisure-time physical activity level correlates well with both cardiovascular (CV) and non-CV mortality in subjects without coronary heart disease (CHD). The impact of leisure-time physical activity on long-term outcomes has not been well studied in patients with preexisting CHD, who are often physically limited because of symptoms, medications, and co-morbid conditions. The aim was to determine the long-term prognostic value of self-reported leisure-time physical activity in a large CHD cohort. Leisure-time physical activity was evaluated using a self-administered questionnaire and categorized using a 4-level scale (sedentary, mild, moderate, and strenuous) in 14,021 of 24,958 subjects from the Coronary Artery Surgery Study Registry with suspected or proven CHD who underwent cardiac catheterization from 1974 to 1979. Median long-term follow-up was 14.7 years (interquartile range 9.8 to 16.2). Clinical outcomes were evaluated according to physical activity level and adjusted for potential confounders. Long-term all-cause and CV mortality progressively increased from most to least active subjects, with sedentary patients showing a 1.6-fold increase in mortality for both these outcomes (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.34 to 1.97, p <0.0001 for all-cause mortality). Similar trends were noted for men and women and in adjusted models, although HRs were attenuated after adjusting for age, gender, smoking, hypertension, diabetes mellitus, total cholesterol, body mass index, and ejection fraction (adjusted HR 1.23, 95% CI 1.01 to 1.49, p = 0.03 for all-cause mortality; adjusted HR 1.25, 95% CI 0.99 to 1.57, p = 0.05 for CV mortality). In conclusion, leisure-time physical activity independently predicted long-term survival in men and women with chronic stable CHD.

Fasting but not postprandial (postmeal) glycemia predicts the risk of death in subjects with coronary artery disease

Chronic hyperglycemia plays a role in the pathogenesis of coronary artery disease (CAD); however, the cut-off level beyond which glycemia becomes detrimental is still controversial. Postprandial glycemia may be a stronger CAD risk factor than fasting glycemia in patients without documented heart disease. To identify the contributions of fasting and postprandial glycemia to cardiovascular risk in patients with documented coronary artery disease. The Coronary Artery Surgery Study (CASS) registry is a database of 24,958 patients with suspected or proven CAD who underwent cardiac catheterization between 1974 and 1979. Median long-term follow up was 14.7 years (interquartile range 9.8 to 16.2 years). Clinical outcomes were evaluated according to fasting glucose levels and 2 h postprandial (postmeal) plasma glucose (2hPG) levels. A total of 13,176 patients with baseline fasting glucose levels and 1691 patients with 2hPG levels were identified. Impaired fasting glycemia was associated with a 1.2-fold increase in both all-cause and cardiovascular mortality (adjusted hazard ratio 1.23; 95% CI 1.08 to 1.40 for cardiovascular mortality), while undiagnosed diabetes was associated with a 1.5-fold increased risk for the same end points. Postprandial hyperglycemia (2hPG of 7.8 mmol/L to 11.0 mmol/L following an average meal) was not associated with a significant risk of death after adjustment for traditional risk factors or in the presence of fasting glucose of less than 6.1 mmol/L. In CAD patients, impaired fasting glucose is associated with increased all-cause and cardiovascular mortality, whereas postprandial hyperglycemia following an average meal does not appear to be a risk factor.

Section 11: Evaluation and Management of Patients With Heart Failure and Preserved Left Ventricular Ejection Fraction

Section 11: Evaluation and Management of Patients With Heart Failure and Preserved Left Ventricular Ejection Fraction

Coronary Artery Surgery

Coronary Artery Surgery

Long-term prognostic value of resting heart rate in patients with suspected or proven coronary artery disease

Heart rate reduction is the cornerstone of the treatment of angina. The purpose of this study was to explore the prognostic value of heart rate in patients with stable coronary artery disease (CAD). We assessed the relationship between resting heart rate at baseline and cardiovascular mortality/morbidity, while adjusting for risk factors. A total of 24 913 patients with suspected or proven CAD from the Coronary Artery Surgery Study registry were studied for a median follow-up of 14.7 years. All-cause and cardiovascular mortality and cardiovascular rehospitalizations were increased with increasing heart rate (P<0.0001). Patients with resting heart rate > or =83 bpm at baseline had a significantly higher risk for total mortality [hazard ratio (HR)=1.32, CI 1.19-1.47, P<0.0001] and cardiovascular mortality (HR=1.31, CI 1.15-1.48, P<0.0001) after adjustment for multiple clinical variables when compared with the reference group. When comparing patients with heart rates between 77-82 and > or =83 bpm with patients with a heart rate < or =62 bpm, the HR values for time to first cardiovascular rehospitalization were 1.11 and 1.14, respectively (P<0.001 for both). Resting heart rate is a simple measurement with prognostic implications. High resting heart rate is a predictor for total and cardiovascular mortality independent of other risk factors in patients with CAD.

Perioperative myocardial injury: individual and population implications

It is generally understood that patients who have cardiovascular disease are at risk of cardiac complications after surgery. In patients undergoing major or vascular surgery, the risk of such complications can be signi®cant. Eagle and colleagues studied patients enrolled on the CASS (Coronary Artery Surgery Study) registry who subsequently underwent non-cardiac surgery. They reported a perioperative myocardial infarction rate of 8.5% in patients with medically managed coronary artery disease who underwent vascular surgery. The authors de®ned high-risk surgery as surgery associated with a risk of perioperative death or myocardial infarction of greater than 4%. Abdominal surgery, thoracic surgery, and head and neck surgery fell into this category. For patients undergoing these types of surgery who had medically treated coronary artery disease, the overall perioperative myocardial infarction rate was 2.7% and the overall death rate 3.3%. This compared with rates of 0.8 and 1% respectively in patients undergoing similar surgery who did not have coronary artery disease. Data such as these are often considered with information on the prevalence of coronary artery disease to obtain some indication of the population burden of disease. For example, in 1990 Mangano stated that 25 million patients undergo major surgery in the USA each year and suggested that perhaps 6±7 million of these people are at risk of perioperative cardiac complications. Such estimates suggest that perioperative cardiac complications are both a major issue in the care of individual surgical patients and a major public health issue. This review will examine in more detail the population impact of perioperative cardiac morbidity and the implications of this for the individual patient.

Effect of chronic infusion of epoprostenol on echocardiographic right ventricular myocardial performance index and its relation to clinical outcome in patients with primary pulmonary hypertension

claudication: factors determining outcome. BMJ 1978;1:1377–1379. 8. Howell MA, Colgan MP, Seeger RW, Ramsey DE, Sumner DS. Relationship of severity of lower limb peripheral vascular disease to mortality and morbidity: a six-year follow-up study. J Vasc Surg 1989;9:691–697. 9. Newman AB, Tyrrell KS, Kuller LH. Mortality over four years in SHEP participants with a low ankle-arm index. J Am Geriatr Soc 1997;45:1472–1478. 10. Newman AB, Siscovick DS, Manolio TA, Polak J, Fried LP, Borhani NO, Wolfson SK. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Circulation 1993;88:837–845. 11. Leng GC, Fowkes FGR, Lee AJ, Dunbar J, Housley E, Ruckley CV. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ 1996;313:1440–1444. 12. Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, Jones DN. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997;26:517–538. 13. European Working Group on Critical Leg Ischaemia. Second European consensus document on chronic critical leg ischemia. Circulation 1991;84(suppl IV):IV-1–IV-26. 14. Vaudo G, Schillaci G, Evangelista F, Pasqualini L, Verdecchia P, Mannarino E. Arterial wall thickening at different sites and its association with left ventricular hypertrophy in newly diagnosed essential hypertension. Am J Hypertens 2000;13:324–331. 15. Department of Health and Human Services. The International Classification of Diseases, 9th Revision, Clinical modification: ICD-9-CM, 3rd Edition; Washington, DC: Government Printing Office, 1989. 16. Kaplan ER, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–481. 17. Cox DR. Regression models and life-tables. J Roy Stat Soc B 1972;34:187–220. 18. Collet D. Modeling Survival Data in Medical Research. London, UK: Chapman and Hall, 1994;72–85. 19. Barzilay JI, Kronmal NA, Bittner V, Eaker E, Evans C, Foster ED. Coronary artery disease in diabetic patients with lower-extremities arterial disease: disease characteristics and survival. A report from the Coronary Artery Surgery Study (CASS) registry. Diabetes Care 1997;20:1381–1387.

Prior coronary artery bypass surgery and risk of death among patients with ischemic left ventricular dysfunction.

Patients with ischemic LV dysfunction are at high risk of sudden death. However, no benefit from prophylactic defibrillator therapy was observed in a group of patients with LV dysfunction undergoing CABG (CABG Patch trial). Thus, the effect of CABG on future risk of sudden death in patients with LV dysfunction is of considerable interest. Mortality and modes of death in 5410 patients with ischemic LV dysfunction who were enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trials were evaluated. Outcomes of patients with (n=1870, 35%) versus without (n=3540) history of prior CABG were compared, and stratification by baseline ejection fraction (EF) values (<0.25, 0.25 to 0.30, and >0.30) was performed. Prior CABG was associated with a 25% (95% CI, 15% to 36%) reduction in risk of death and a 46% (95% CI, 30% to 58%) reduction in risk of sudden death independent of EF and severity of heart failure symptoms. As baseline EF declined, absolute reduction in risk of sudden death with prior CABG increased (P<0.01). No alteration in risk of death from progressive heart failure was observed with prior CABG. When these results were applied to a group of patients with LV dysfunction who had not undergone prior surgery (Coronary Artery Surgery Study Registry) predicted annual rates of death (8.2%) and sudden death (2.4%) were similar to those observed in the CABG Patch trial (7.9% and 2.3%, respectively). In patients with ischemic LV dysfunction, prior CABG is associated with a significant independent reduction in mortality. These results appear to account for the lack of benefit from defibrillator therapy in the CABG Patch trial.

Revascularization Versus Implantable Cardioverter-Defibrillators to Prevent Sudden Death in Patients With Severe Left Ventricular Dysfunction

Sudden death remains a dreaded consequence of coronary artery disease, and efforts to predict its incidence and to prevent its occurrence remain a major concern. A number of the challenges in management are highlighted in the article by Veenhuyzen et al1 in the present issue of Circulation . In their study, mortality and modes of death were assessed in 5410 patients with ischemic left ventricular function who were enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) study.2 There were 1870 patients who had had prior coronary artery bypass grafting (CABG) and 3540 who had not had prior CABG. The SOLVD trial database is a good source for these data, both because it is large and because the cause of death (ie, whether cardiac and whether sudden or not) was established. See p 1489 The key findings of Veenhuyzen et al1 are that CABG was associated with a 25% reduction in the risk of death (from 24.3% to 18.4%) and a 46% reduction in the risk of sudden death (from 7.5% to 4.1%). These findings are independent of ejection fraction, severity of heart failure symptoms, age, and other clinical variables. In a stratified analysis by severity of left ventricular dysfunction, there was some evidence for interaction, but similar results were noted overall. Prior CABG was not associated with an alteration in the risk of death from progressive heart failure. The results were applied to a group of patients with left ventricular dysfunction from the Coronary Artery Surgery Study Registry who had not undergone surgery, offering a predicted annual rate of death of 8.2% and sudden death …

Evaluation of patients with chest pain and normal coronary angiograms.

Over 1 million coronary angiograms are performed in North America annually, and a significant number are interpreted as normal. In the Coronary Artery Surgery Study Registry of the 1970s, normal angiograms were found in 19% of patients,' and the prevalence may not have changed in the current era of more sophisticated noninvasive testing. A recent study found that 19% of patients had no arteriographic evidence of disease.2 2 For women selected for angiography, a normal result is found 3 times more frequently than for men. 1,2 Further elucidation of the diagnosis in a patient population of this size is of obvious importance. However, correctly investigating and managing the treatment for such patients can be challenging. On the one hand, a potentially serious, yet manageable condition must not be overlooked. On the other hand, excessive anxiety over a problem that may not exist or may not be serious must not be created. Therefore, the finding of a normal angiogram in a patient with chronic chest pain in whom coronary disease was suspected prior to the procedure must lead to a thorough investigation (Figure 1). The pathophysiologic features, investigation, and treatment of chest pain in these patients are the subject of this review.

CASS registry: Long term surgical survival

ObjectivesTo show the effect of clinical, angio and demographic traits on late survival of Coronary Artery Surgery Study (CASS) patients following coronary artery bypass grafting (CABG) and introduce Hazard Function analysis to CASS survival data.MethodsPatients were reached by mail survey with 94% response. By National Death Index, vital status was obtained in 99.7% (n = 8221) with a mean follow up of 15 years. Cox proportional hazard and Blackstone Hazard Function regressions were used to assess effects of preoperative traits.ResultsNinety percent of patients were alive at 5, 74% at 10 and 56% at 15 years. Of those age 65 and age 75 at operation, 74% and 59% were living at 10 years and 54% and 33% at 15 years (now age 90), survival exceeding the matched U.S. population. Hazard Function falls rapidly after CABG to 9 to 12 months, then rises, doubling by 15 years. Young patients, below age 35, had lower late survival. The time-segmented Cox model (divided at time suggested by the Hazard Function) identified traits showing predictive power early, throughout and late. Female sex, small body surface, ischemic symptoms and emergency status affected survival early. Heavier weight, infarct(s), diuretics, diabetes, smoking, left main and LAD stenosis and use of vein grafts only increased hazard late only.ConclusionsThere are still lessons from the CASS database. CABG in the elderly is supported by the survival pattern of our patients age 75 at operation. Time-segmented Cox analysis and Hazard Function analysis separate baseline variables into those that predict early mortality and those that predict long survival.

Coronary artery disease in diabetic and nondiabetic patients with lower extremity arterial disease: A report from the Coronary Artery Surgery Study Registry

Objective: Patients with lower extremity arterial disease (LEAD) are at an increased risk of having coronary artery disease (CAD). Diabetics are at especially high risk for having LEAD with concomitant CAD. This study was undertaken (1) to define the clinical and arteriographic features associated with CAD among diabetics and nondiabetics with LEAD and (2) to determine the long-term survival and predictors of mortality of diabetics and nondiabetics with LEAD and CAD. Research Design and Methods: Two hundred sixty-three diabetics and 1137 nondiabetics from the Coronary Artery Surgery Study who had evidence of LEAD, who were 50 years and older, and who had arteriographically proven CAD were monitored for a mean of 12.8 years. Results: Among all the subjects with LEAD there was a high prevalence of current and past smoking, history of previous myocardial infarction, systemic hypertension, congestive heart failure, high degrees of angina pectoris and unstable angina pectoris, and use of β-blockers. On arteriographic evaluation a high prevalence of three-vessel epicardial coronary disease and involvement of multiple coronary segments with ≥50% diameter narrowing was found. Multivariate analysis showed the number of coronary segments with ≥50% occlusion, the presence of cerebrovascular disease, the use of digitalis, and elevated systolic blood pressure were independently associated with diabetes. On follow-up diabetics had a significantly higher mortality rate (mostly cardiac) than nondiabetics: median survival, 8.1 years and 12.7 years, respectively. At 15 years the mortality rates were 77.1% and 62.0%, respectively. On multivariate analysis, age, number of coronary occlusions, number of significantly narrowed epicardial arteries, diminished myocardial contractility, hypertension, and smoking were significant predictors of mortality in the total group and in each subgroup. Coronary artery bypass grafting surgery was protective. The presence of diabetes was an independent risk factor for mortality. Conclusions: The presence of LEAD is associated with multivessel epicardial and multiple coronary segment occlusion. On long-term follow-up there is a high mortality rate. In patients with LEAD and diabetes, CAD is especially severe and prognosis is poor. (Am Heart J 1998;135:1055-62.)