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Effective Lipid Modification by Partial Ileal Bypass Reduced Long-term Coronary Heart Disease Mortality and Morbidity: Five-Year Posttrial Follow-up Report From the POSCH
Henry Buchwald, MD, PhD;
Richard L. Varco, MD, PhD;
James R. Boen, PhD;
Stanley E. Williams, MHA;
Betty J. Hansen, RN;
Christian T. Campos, MD;
Gilbert S. Campbell, MD, PhD;
Malcolm B. Pearce, MD;
Albert E. Yellin, MD;
W. Allan Edmiston, MD;
Robert D. Smink, Jr, MD;
Henry S. Sawin, Jr, MD;
for the POSCH Group
Arch Intern Med. 1998;158:1253-1261.
Background In 1990, when the Program on the Surgical Control of the Hyperlipidemias (POSCH) reported its in-trial results strongly supporting the conclusion that effective lipid modification reduces progression of atherosclerosis, the differences for the end points of overall mortality and mortality from atherosclerotic coronary heart disease (ACHD) did not reach statistical significance.
Methods The Program on the Surgical Control of the Hyperlipidemias recruited men and women with a single documented myocardial infarction between the ages of 30 and 64 years who had a plasma cholesterol level higher than 5.69 mmol/L (220 mg/dL) or higher than 5.17 mmol/L (200 mg/dL) if the low-density lipoprotein cholesterol level was in excess of 3.62 mmol/L (140 mg/dL). Between 1975 and 1983, 838 patients were randomized: 417 to the diet control group and 421 to the diet plus partial ileal bypass intervention group. Mean patient follow-up for this 5-year posttrial report was 14.7 years (range, 12.2-20 years).
Results At 5 years after the trial, statistical significance was obtained for differences in overall mortality (P=.049) and mortality from ACHD (P=.03). Other POSCH end points included overall mortality (left ventricular ejection fraction  50%) (P=.01), mortality from ACHD (left ventricular ejection fraction 50%) (P=.05), mortality from ACHD and confirmed nonfatal myocardial infarction (P<.001), confirmed nonfatal myocardial infarction (P<.001), mortality from ACHD, confirmed and suspected myocardial infarction and unstable angina (P<.001), incidence of coronary artery bypass grafting or percutaneous transluminal coronary angioplasty (P<.001), and onset of clinical peripheral vascular disease (P=.02). There were no statistically significant differences between groups for cerebrovascular events, mortality from non-ACHD, and cancer. All POSCH patients have been available for follow-up.
Conclusion At 5 years after the trial, all POSCH mortality and atherosclerosis end points, including overall mortality and mortality from ACHD, demonstrated statistically significant differences between the study groups.
From the Department of Surgery (Drs Buchwald and Varco, Mr Williams, and Ms Hansen) and the School of Public Health (Dr Boen), University of Minnesota, Minneapolis; the Departments of Surgery (Dr Campbell) and Medicine (Dr Pearce), University of Arkansas for Medical Sciences, Little Rock; the Departments of Surgery (Dr Yellin) and Medicine (Dr Edmiston), University of Southern California, Los Angeles; the Departments of Surgery (Dr Smink) and Radiology (Dr Sawin), Lankenau Hospital and Research Center, Philadelphia, Pa; and the Division of Cardiothoracic Surgery, Beth Israel-Deaconess Medical Center and Harvard Medical School, Boston, Mass (Dr Campos).
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