[HSF] Stent-vs-surgery debate heats up again
prasannasimha
prasannasimha at gmail.com
Thu Apr 5 20:35:10 EDT 2007
Mladlen,
I was next door in Zagreb. !!
I tried to contact you but failed !!
Prasanna
Tina i Mladen Kocica wrote:
>
> Why don't you write a case report?!? Newspaper article? Isn't it terrible practice to remain silent and leave some people, doing unoposed (mal)practice, alone? Should we wait for patients to start asking questions ... Or ... Possibly we could have some answers.
> Isolated CABG volume, in this part of the world, unfortunately, did not drop down, in spite of PCI. The main reason is true epidemic. Our system can hardly bare even current volume, but this fact still does not mean that PCI is better for each patient. Moreover, if patients continue to receive positive recommendations for PCI and frightening one for surgery - we could not expect from the society (government) to realize that our cardiac surgical capacities should be substantially better. In other words - if country decides to pay for PCI much more than for surgery - this would exaust our specialty and won't bring a long term benefit to people in need. Finally, who's gonna tell the politicians (i.e. government) that surgery is not "old-fashioned, expensive, ugly and dangerous". Who's gonna explain that net price of 9 stents and heartmate VAD is VERY MUCH higher than LIMA-LAD. They do not undestand health benefits, but they do understand number of zeroes in price.
>
> Mladen J. Kocica, M.D.
>
>
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Michael Firstenberg
> Sent: 25. mart 2007 03:39
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Stent-vs-surgery debate heats up again
>
> We just transplanted today a young woman (45 years/old) who we put a heartmate II VAD in several months ago when she presented in cardiogenic shock when the most proximal of her 9 (yes NINE) LAD stents went down.......
>
> no doubt that stents and DES have a role in the management of CAD...... patients are starting to ask more questions.
>
>
> by the way - as we have all been downsizing from isolated CABG volume and/or doing more valve cases - can your systems accommodate an acute 10-20% increase in isolated CABG volume?
>
> michael
>
>
> On Mar 24, 2007, at 9:25 PM, Tina i Mladen Kocica wrote:
>
>
>>
>> It is not "them vs us" and DEFINITIVELY it is not a matter of
>> "mentality". Why don't we give this thing a real name?
>> This is a big fraud for big money. Just think about "science and
>> ethic" of the LMCA stenting trials? G!
>> I could not add much more to David Taggart's recent talks (STS) and
>> papers (ATS, EJCTS...). This is not any "against" attitude but the
>> language of evidence we have to adopt.
>> Lionel Opie et al. stated in:
>> Controversies in stable coronary artery disease • REVIEW ARTICLE
>> The Lancet, Volume 367, Issue 9504, 7 January 2006-13 January 2006,
>> Pages 69-78
>> Lionel H Opie, Patrick J Commerford and Bernard J Gersh “In view of
>> the survival benefit shown for coronary-artery bypass grafting, the
>> real controversy is why patients with symptoms and anatomy known to
>> benefit from the procedure are still submitted to percutaneous
>> coronary intervention.”
>> I think that all of us should read this paper and Taggart's response:
>> Controversies in cardiology • CORRESPONDENCE
>> The Lancet, Volume 367, Issue 9519, 22 April 2006-28 April 2006, Page
>> 1313
>> David P Taggart
>> I doubt that (m)any of us are doing "Favoloro's time" coronary surgery
>> today. Even so, I have seen functional Vineberg graft after
>> 3 decades. Does anybody know a patient with any kind of PCI, with 5
>> years period free of any event?
>> I don't think this debate should continue between surgeons. It's much
>> better for us to start talking loudly and clearly to our patients and
>> insurance companies.
>> Personally, I do believe that PCI should exist - but: 1) for VERY
>> selected group of patients as a single, primary treatment, and 2)
>> (more important) as a part of hybrid revascularization.
>> Finally, I am disappointed with this "global medico-industrial trend"
>> and the best I can do, is to be well prepared for end-stage ischemic
>> heart failure surgery, because, those CAD patients who would be lucky
>> enough to survive PCI adventure(s), would come to us with very big
>> hearts.
>>
>> Mladen J. Kocica, M.D.
>>
>> Clinic for Cardiac Surgery
>> Institute for Cardiovascular Diseases
>> UC Clinical Centre of Serbia
>> 8th Kosta Todorovic St.
>> 11000 Belgrade
>> Serbia
>> Tel: + 381 (11) 3670609
>> Fax: + 381 (11) 3610880
>> E-mail: kocica at sezampro.yu
>> URL: www.kocica.org
>> URL: www.ctsnet.org/home/mkocica
>> URL: www.srscvs.org
>>
>>
>>
>> -----Original Message-----
>> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
>> bounces at lists.hsforum.com] On Behalf Of Michael Firstenberg
>> Sent: 25. mart 2007 01:11
>> To: OpenHeart-L at lists.hsforum.com
>> Subject: Re: [HSF] Stent-vs-surgery debate heats up again
>>
>> Hiding behind data -
>> We have spent decades perfecting (although far from perfect) all
>> aspects of a highly technical procedure - just look at this forum,
>> every step of the way has been studied, reviewed, and examined
>> scientifically. Drugs have gotten better, CPB has gotten better,
>> tools have gotten better, anesthesia, post-op care, myocardial
>> protected, and so on. I recently got into a discussion regarding the
>> treatment of acute PE - surgery vs tPA and realized the operative
>> mortality from a "simple" pump run is better than a dose
>> of tPA and many other medical treatments for surgery problems.
>> Look at the Cleveland Clinic published data (www.ccf.org) - their
>> operative mortality following CABG is lower than there mortality from
>> PCI.....
>>
>> we are getting better - we just have to convince others of that.....
>>
>>
>> -michael
>>
>>
>> On Mar 24, 2007, at 7:46 PM, Ani Anyanwu wrote:
>>
>> > It is folly to think that we (surgeons) have the solution to
>> coronary
>> > artery disease. The fact that there is abundance of evidence
>> showing
>> > we have the best treatment available, yet the reality being that
>> most
>> > patients and cardiologists chose not to embrace our treatment,
>> shows
>> > that our therapy (CABG) is far from optimal. Patients and
>> > cardiologists are voting with their feet.
>> > Indeed the refusal to embrace surgery reflects a rejection of our
>> > therapy and makes it imperative to seek better solutions to
>> coronary
>> > stenosis.
>> >
>> > While DES may not be the solution, CABG won't be either. There may
>> > well be a resurgence in CABG (and decline in DES) in the short term
>> as
>> > scientists and clinicians seek better solutions to coronary
>> stenosis,
>> > but it would be naïve to think aortocoronary bypass will be the
>> gold
>> > standard therapy for coronary stenosis in the 21st century as it
>> was
>> > 30 years ago.
>> >
>> > By the way statistics do reveal it all in the DES saga. I read the
>> BMJ
>> > papers and none of them is remotely evidence of superiority of
>> > surgery. One shows surgery is cost effective in SVD, other shows no
>> > difference between PCI and MIDCAB in SVD (which is irrelevant as
>> few
>> > do MIDCAB and few promote surgery for single vessel disease) in MI
>> or
>> > survival and the third is based on hypothetical modeling of an
>> > irrelevant 1996/7 cohort.
>> >
>> > I think the sooner we move away from the "them vs us" mentality,
>> the
>> > better it will be for the renaissance of our specialty. Our future
>> > cannot be in a 30 year-old operation - we need to accept that and
>> move
>> > on. Mind you surgery might be part of the future solution - we
>> however
>> > have to accept that LIMA and veins on-pump is not; unless we accept
>> > this and move on, the future will leave us behind time warped in
>> the
>> > Favalaro operation of the 1970s. Hiding behind data and randomized
>> > trials as an excuse to keep promoting a four decade old procedure
>> will
>> > not get us anywhere.
>> >
>> > Ani
>> > ----- Original Message -----
>> > From: Michael Firstenberg<mailto:msfirst at gmail.com>
>> > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
>> > L at lists.hsforum.com>
>> > Sent: Saturday, March 24, 2007 5:06 PM
>> > Subject: Re: [HSF] Stent-vs-surgery debate heats up again
>> >
>> >
>> > I learned a long time ago from a very good friend - statistics
>> are
>> > like a string bikini.
>> > What they reveal is interesting, was they cover is ........
>> well you
>> > can fill in the blank
>> >
>> > If you peel away some of the statistics, you get the sense
>> that the
>> > complication rate in "real world" is much higher. In
>> addition, the
>> > papers were all written by those who have made their careers by
>> > putting these in and advocating their widespread use.
>> >
>> > I think that DES have been the best thing for our practice - at
>> > least
>> > half of the VADs we putting in are in patients who have
>> thrombosed
>> > proximal LAD stents. Many of the CABGs that I have done
>> lately have
>> > been in patients with occluded or stenotic stents in multi-vessel
>> > disease. These bring patients into the system - it is
>> unfortunately
>> > that the complications can be catastrophic. The global impact of
>> > this problem may be huge and like a hurricane - hopefully the
>> damage
>> > to the long standing data and science of the treatment and
>> > management
>> > of coronary disease will not be in the path. We are all
>> likely to
>> > get wrapped up in this in ways we might like.......
>> >
>> >
>> >
>> > We, as surgeons, need to write some papers from our experience,
>> > stent
>> > thrombosis and associated complications get kind of "glossed"
>> > over in
>> > some of these large population or highly controlled studies.
>> >
>> >
>> > -michael
>> >
>> >
>> > On Mar 24, 2007, at 5:51 PM, A wrote:
>> >
>> >> Thanks for these good references. Please keep the HSF posted.
>> >>
>> >> Ahmed
>> >>
>> >> -----Original Message-----
>> >> From: openheart-l-bounces at lists.hsforum.com<mailto:openheart-l-
>> >> bounces at lists.hsforum.com> [mailto:openheart-l-
>> >> bounces at lists.hsforum.com<mailto:bounces at lists.hsforum.com>] On
>> >> Behalf Of M. A. Quader, MD
>> >> Sent: Friday, March 23, 2007 12:22 PM
>> >> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
>> >> L at lists.hsforum.com>
>> >> Subject: Re: [HSF] Stent-vs-surgery debate heats up again
>> >>
>> >> There is more to the debate,longterm outcome information on DES
>> vs.
>> >> BMS was
>> >> published in NEJM,, March 8 issue of 2007. Five original articles,
>> >> two editorials
>> >> and one FDA perspective. Bottom line, if DES are used out side of
>> >> study patients
>> >> (single vessel, simple lesions) there is an incremental mortality
>> >> of 0.5% per year
>> >> compared to BMS. I have never seen NEJM ever take an issue to this
>> >> extent ever
>> >> before, we must read that issue and share the information with
>> >> cardiologists and
>> >> family physicians.
>> >>
>> >> Thanks.
>> >> Mo
>> >>
>> >>>
>> >>> Stent-vs-surgery debate heats up again
>> >>>
>> >>> Mar 22, 2007Sue Hughes
>> >>>
>> >>> London and York, UK - Three new studies, published in the March
>> >>> 24, 2007 issue of
>> >>> BMJ, have questioned the clinical and cost effectiveness of
>> >>> stenting and suggest
>> >>> that surgery may be the better option for many patients. In an
>> >>> accompanying
>> >>> editorial [1], cardiac surgeon Prof David Taggart (University of
>> >>> Oxford, UK) says
>> >>> these studies "raise key issues not only about the decision-
>> making
>> >>> process for
>> >>> intervention in the individual patient but also how to obtain
>> >>> maximum value from
>> >>> limited health-service resources." In an interview with
>> heartwire,
>> >>> Taggart claimed
>> >>> that many patients are never even informed about the possible
>> >>> benefits of surgery,
>> >>> as the decision process is handled by an interventional
>> >>> cardiologist. Taggart is
>> >>> calling for a change in the way these patients are managed, with
>> a
>> >>> multidisciplinary team being involved in the decision as to
>> >>> whether to treat with
>> >>> stent or surgery. Commenting on these papers for heartwire,
>> >>> interventionalist Dr
>> >>> Robert Harrington (Duke University, Durham, NC) said these
>> studies
>> >>> and editorial
>> >>> demonstrate a growing concern among cardiac surgeons that their
>> >>> livelihood is
>> >>> being threatened by PCI, which has evolved over recent years to
>> be
>> >>> the dominant
>> >>> form of CAD revascularization. But he added that the call for
>> >>> interdisciplinary
>> >>> teams to evaluate the revascularization options with patients was
>> >>> an interesting
>> >>> idea and one that might be beneficial for patients.
>> >>>
>> >>>
>> >>> LAD single-vessel-disease meta-analysis
>> >>> The first two papers look at patients with single-vessel disease
>> >>> of the left
>> >>> anterior descending (LAD) coronary artery [2,3]. The authors, led
>> >>> by Dr Omer Aziz
>> >>> (Imperial College London, UK), conducted a meta-analysis of 12
>> >>> studies comparing
>> >>> the best percutaneous intervention (transluminal coronary artery
>> >>> stenting) with
>> >>> the least invasive surgical intervention (minimally invasive
>> >>> direct coronary
>> >>> artery bypass with left internal thoracic artery) in such
>> >>> patients. Results showed
>> >>> that patients who received stents had a higher rate of recurrence
>> >>> of angina, more
>> >>> major adverse coronary and cerebral events, and more repeat
>> >>> revascularizations
>> >>> than those who underwent surgery. But there was no significant
>> >>> difference in MI,
>> >>> stroke, or mortality at maximum follow-up between interventions.
>> >>> The researchers
>> >>> conclude that the findings suggest that minimally invasive direct
>> >>> coronary artery
>> >>> bypass produces a more definitive revascularization in the mid
>> >>> term in these
>> >>> patients.
>> >>>
>> >>>
>> >>> Surgery cost-effective in long-term
>> >>> The second paper, by the same group, looked at the cost-
>> >>> effectiveness of these
>> >>> procedures, again in patients with single-vessel disease of the
>> >>> LAD. Results
>> >>> showed that stenting was more effective and less costly than
>> >>> bypass surgery in the
>> >>> first two years, but in the third year, bypass surgery, while
>> >>> still more
>> >>> expensive, became marginally more effective, although not cost-
>> >>> effective at this
>> >>> point. However, by 10 years, the authors say, surgery "is
>> probably
>> >>> cost-effective," with a cost of £6274.02 per quality-adjusted
>> >>> life year (QALY).
>> >>> They conclude that minimally invasive left internal thoracic
>> >>> artery bypass is more
>> >>> effective than stenting in the long term, justifying its initial
>> >>> additional cost,
>> >>> but these findings do not take into account the effect of drug-
>> >>> eluting stents, for
>> >>> which data on long-term effectiveness are awaited The third paper
>> >>> deals with a
>> >>> different group of patients—those with multivessel disease [4].
>> >>> The authors, led
>> >>> by SC Griffin (University of York, UK), conducted an
>> observational
>> >>> study comparing
>> >>> cost-effectiveness of CABG, stenting, or medical management in
>> >>> patients rated as
>> >>> appropriate for revascularization. Results showed that CABG
>> seemed
>> >>> cost-effective
>> >>> but stenting did not. "Cost-effectiveness analysis based on
>> >>> observational data
>> >>> suggests that the clinical benefit of percutaneous coronary
>> >>> intervention may not
>> >>> be sufficient to justify its cost," the researchers conclude.
>> >>>
>> >>>
>> >>> An interventionalist responds
>> >>> Responding to some of these issues for heartwire, interventional
>> >>> cardiologist Dr
>> >>> David Moliterno (University of Kentucky, Lexington) described the
>> >>> meta-analysis by
>> >>> Aziz and colleagues as "provocative," but he pointed out that
>> even
>> >>> with data
>> >>> combined from several studies their data set remains too small to
>> >>> provide new
>> >>> insight or definitive guidance for clinical practice. Moliterno
>> >>> said: "It is well
>> >>> established that percutaneous revascularization and bypass
>> surgery
>> >>> result in
>> >>> similar rates of death and myocardial infarction at long-term
>> >>> follow-up. Yet if
>> >>> the results of the present meta-analysis were extended to 1000
>> >>> surgically treated
>> >>> patients, 17 more deaths and 10 more MIs would occur at maximum
>> >>> follow-up than if
>> >>> the patients had undergone stent placement. In contrast, 97
>> repeat
>> >>> revascularizations would be avoided with bypass surgery. In this
>> >>> study, bare-metal
>> >>> stents were used, but the new drug-eluting stents markedly reduce
>> >>> the rate of
>> >>> repeat revascularizations and therefore could attenuate this
>> >>> benefit of surgery."
>> >>> He added: "Fortunately, large-scale, prospective studies are
>> >>> ongoing with the
>> >>> SYNTEX and FREEDOM trials, together randomizing more than 4000
>> >>> patients to
>> >>> multivessel bypass surgery vs drug-eluting-stent placement."
>> >>>
>> >>>
>> >>> A moving target?
>> >>> But Taggart argues that this is simply moving the goalposts.
>> >>> "There have been
>> >>> hosts of studies showing surgery gives better results than
>> >>> stenting over the past
>> >>> 20 years, but interventional cardiologists keep on moving the
>> >>> target. When surgery
>> >>> was shown to be better than balloon angioplasty, they said, "Wait
>> >>> for the stent
>> >>> studies,' and now they are saying, 'Wait for the drug-eluting-
>> >>> stent studies.' " He
>> >>> also believes that the benefit of surgery has been underestimated
>> >>> in most studies,
>> >>> as patients with more severe disease were excluded. "Most studies
>> >>> comparing stents
>> >>> and surgery have enrolled patients with minimal disease, and a
>> >>> survival benefit is
>> >>> not going to show up in these patients. But these results have
>> >>> been rolled out to
>> >>> justify using stents in all patients. This is a complete
>> >>> distortion of the
>> >>> evidence," he commented to heartwire Taggart admits that,
>> >>> conceptually, stenting
>> >>> is obviously a popular option. "If you can achieve the same
>> >>> results without having
>> >>> to open the chest, of course this will be appealing. But the
>> >>> result is often not
>> >>> the same. And there is enormous pressure from the stent industry,
>> >>> which inevitably
>> >>> influences the situation." He points out that there is much more
>> >>> evidence in
>> >>> favor of surgery in patients with multivessel disease, with a
>> >>> survival benefit
>> >>> having been shown in this group, but there is still an increasing
>> >>> tendency for
>> >>> these patients to get stents. Taggart believes the fact that
>> >>> interventional
>> >>> cardiologists alone make the decision of whether stents or
>> surgery
>> >>> should be used
>> >>> is the stumbling block here. "A significant number of patients
>> >>> don't even know
>> >>> that surgery is an option. Patients need to be given all the
>> >>> information on the
>> >>> options before the decision as to which way to go is made. "Yes,
>> >>> there is the
>> >>> supermarket convenience of inserting a stent while the patient is
>> >>> there in the
>> >>> cath lab rather than having to schedule another procedure time,
>> >>> but this is not a
>> >>> trivial decision. It is not reasonable for this decision to be
>> >>> made in a couple of
>> >>> minutes when the patent is lying on the cath-lab table. The
>> >>> different options need
>> >>> to be explained thoroughly, with input from both
>> >>> interventionalists and surgeons."
>> >>> Taggart says some lesions can be stented there and then in the
>> >>> cath lab and no
>> >>> one will argue—for example, single-vessel disease that is not
>> >>> proximal and for
>> >>> which stenting will not block a side branch. "But for more
>> >>> complicated
>> >>> single-vessel lesions and all multivessel disease, the treatment
>> >>> procedure should
>> >>> be separated from the diagnostic procedure and not undertaken
>> >>> until the patient
>> >>> has been informed of all the options," he concludes.
>> >>>
>> >>>
>> >>> Stop the "mine-is-better-than-yours" mentality
>> >>> Harrington comments that Taggart has some interesting ideas but
>> >>> that too much
>> >>> effort (and marketing money) is spent on the "mine-is-better-
>> than-
>> >>> yours" mentality
>> >>> and that instead all parties should work together to address the
>> >>> questions that
>> >>> will truly allow better healthcare. "Care for patients with
>> >>> obstructive CAD should
>> >>> be evidence based, and PCI and CABG should be thought of as
>> >>> complementary
>> >>> procedures with benefits (and risks) for different categories of
>> >>> patients based on
>> >>> CAD anatomy, LV function, other comorbid conditions, and patient
>> >>> values and
>> >>> preferences," he concludes.
>> >>>
>> >>>
>> >>>
>> >>> Sources
>> >>>
>> >>>
>> >>> Taggart DP. Coronary revascularization surgery is effective on
>> >>> clinical and
>> >>> economic grounds, but stenting does not seem to be cost
>> effective.
>> >>> BMJ 2007;
>> >>> 334:593-594. Aziz O, Rao C, Panesar SS et al. Meta-analysis of
>> >>> minimally
>> >>> invasive internal thoracic artery bypass versus percutaneous
>> >>> revascularisation for
>> >>> isolated lesions of the left anterior descending artery. BMJ
>> 2007;
>> >>> 334:617-621.
>> >>> Rao C, Aziz O, Panesar SS et al. Cost effectiveness analysis of
>> >>> minimally invasive
>> >>> internal thoracic artery bypass versus percutaneous
>> >>> revascularisation for isolated
>> >>> lesions of the left anterior descending artery. BMJ 2007;
>> >>> 334:621-624. Griffin
>> >>> SC, Barber JA, Manca A. Cost effectiveness of clinically
>> >>> appropriate decisions on
>> >>> alternative treatments for angina pectoris: prospective
>> >>> observational study. BMJ
>> >>> 2007; 334:624-628.
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>> Edward P. Raines, M.D., J.D.
>> >>> BryanLGH Cardiothoracic Surgery
>> >>> BryanLGH Medical Center East
>> >>> 1600 South 48th Str.
>> >>> Lincoln, Nebraska 68506
>> >>> Office: 402-481-8430
>> >>> Cell: 402-730-9242
>> >>> Fax: 402-481-8429
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>> AOL now offers free email to everyone. Find out more about what's
>> >>> free from AOL at
>> >>> AOL.com. Attached Message
>> >>> From:sendArticles at theheart.org
>> >>> To:dukeB60 at aol.com
>> >>> Subject:{Disarmed} Stent-vs-surgery debate heats up again
>> >>> Date:Thu, 22 Mar 2007 8:46 PM
>> >>>
>> >>> At the request of Clyde Meckel
>> >>> (drmeckel at bhi-1.com<mailto:drmeckel at bhi-1.com>), you are being
>> >>> sent a link to
>> >>> an article from theheart.org, the website for cardiovascular
>> >>> health professionals.
>> >>>
>> >>> Message from Clyde Meckel : NAAAAAAH
>> >>>
>> >>>
>> >>> Stent-vs-surgery debate heats up again
>> >>>
>> >>> Mar 22, 2007Sue Hughes
>> >>>
>> >>> London and York, UK - Three new studies, published in the March
>> >>> 24, 2007 issue of
>> >>> BMJ, have questioned the clinical and cost effectiveness of
>> >>> stenting and suggest
>> >>> that surgery may be the better option for many patients. In an
>> >>> accompanying
>> >>> editorial [1], cardiac surgeon Prof David Taggart (University of
>> >>> Oxford, UK) says
>> >>> these studies "raise key issues not only about the decision-
>> making
>> >>> process for
>> >>> intervention in the individual patient but also how to obtain
>> >>> maximum value from
>> >>> limited health-service resources." In an interview with
>> heartwire,
>> >>> Taggart claimed
>> >>> that many patients are never even informed about the possible
>> >>> benefits of surgery,
>> >>> as the decision process is handled by an interventional
>> >>> cardiologist. Taggart is
>> >>> calling for a change in the way these patients are managed, with
>> a
>> >>> multidisciplinary team being involved in the decision as to
>> >>> whether to treat with
>> >>> stent or surgery. Commenting on these papers for heartwire,
>> >>> interventionalist Dr
>> >>> Robert Harrington (Duke University, Durham, NC) said these
>> studies
>> >>> and editorial
>> >>> demonstrate a growing concern among cardiac surgeons that their
>> >>> livelihood is
>> >>> being threatened by PCI, which has evolved over recent years to
>> be
>> >>> the dominant
>> >>> form of CAD revascularization. But he added that the call for
>> >>> interdisciplinary
>> >>> teams to evaluate the revascularization options with patients was
>> >>> an interesting
>> >>> idea and one that might be beneficial for patients.
>> >>>
>> >>>
>> >>> LAD single-vessel-disease meta-analysis
>> >>> The first two papers look at patients with single-vessel disease
>> >>> of the left
>> >>> anterior descending (LAD) coronary artery [2,3]. The authors, led
>> >>> by Dr Omer Aziz
>> >>> (Imperial College London, UK), conducted a meta-analysis of 12
>> >>> studies comparing
>> >>> the best percutaneous intervention (transluminal coronary artery
>> >>> stenting) with
>> >>> the least invasive surgical intervention (minimally invasive
>> >>> direct coronary
>> >>> artery bypass with left internal thoracic artery) in such
>> >>> patients. Results showed
>> >>> that patients who received stents had a higher rate of recurrence
>> >>> of angina, more
>> >>> major adverse coronary and cerebral events, and more repeat
>> >>> revascularizations
>> >>> than those who underwent surgery. But there was no significant
>> >>> difference in MI,
>> >>> stroke, or mortality at maximum follow-up between interventions.
>> >>> The researchers
>> >>> conclude that the findings suggest that minimally invasive direct
>> >>> coronary artery
>> >>> bypass produces a more definitive revascularization in the mid
>> >>> term in these
>> >>> patients.
>> >>>
>> >>>
>> >>> Surgery cost-effective in long-term
>> >>> The second paper, by the same group, looked at the cost-
>> >>> effectiveness of these
>> >>> procedures, again in patients with single-vessel disease of the
>> >>> LAD. Results
>> >>> showed that stenting was more effective and less costly than
>> >>> bypass surgery in the
>> >>> first two years, but in the third year, bypass surgery, while
>> >>> still more
>> >>> expensive, became marginally more effective, although not cost-
>> >>> effective at this
>> >>> point. However, by 10 years, the authors say, surgery "is
>> probably
>> >>> cost-effective," with a cost of £6274.02 per quality-adjusted
>> >>> life year (QALY).
>> >>> They conclude that minimally invasive left internal thoracic
>> >>> artery bypass is more
>> >>> effective than stenting in the long term, justifying its initial
>> >>> additional cost,
>> >>> but these findings do not take into account the effect of drug-
>> >>> eluting stents, for
>> >>> which data on long-term effectiveness are awaited The third paper
>> >>> deals with a
>> >>> different group of patients—those with multivessel disease [4].
>> >>> The authors, led
>> >>> by SC Griffin (University of York, UK), conducted an
>> observational
>> >>> study comparing
>> >>> cost-effectiveness of CABG, stenting, or medical management in
>> >>> patients rated as
>> >>> appropriate for revascularization. Results showed that CABG
>> seemed
>> >>> cost-effective
>> >>> but stenting did not. "Cost-effectiveness analysis based on
>> >>> observational data
>> >>> suggests that the clinical benefit of percutaneous coronary
>> >>> intervention may not
>> >>> be sufficient to justify its cost," the researchers conclude.
>> >>>
>> >>>
>> >>> An interventionalist responds
>> >>> Responding to some of these issues for heartwire, interventional
>> >>> cardiologist Dr
>> >>> David Moliterno (University of Kentucky, Lexington) described the
>> >>> meta-analysis by
>> >>> Aziz and colleagues as "provocative," but he pointed out that
>> even
>> >>> with data
>> >>> combined from several studies their data set remains too small to
>> >>> provide new
>> >>> insight or definitive guidance for clinical practice. Moliterno
>> >>> said: "It is well
>> >>> established that percutaneous revascularization and bypass
>> surgery
>> >>> result in
>> >>> similar rates of death and myocardial infarction at long-term
>> >>> follow-up. Yet if
>> >>> the results of the present meta-analysis were extended to 1000
>> >>> surgically treated
>> >>> patients, 17 more deaths and 10 more MIs would occur at maximum
>> >>> follow-up than if
>> >>> the patients had undergone stent placement. In contrast, 97
>> repeat
>> >>> revascularizations would be avoided with bypass surgery. In this
>> >>> study, bare-metal
>> >>> stents were used, but the new drug-eluting stents markedly reduce
>> >>> the rate of
>> >>> repeat revascularizations and therefore could attenuate this
>> >>> benefit of surgery."
>> >>> He added: "Fortunately, large-scale, prospective studies are
>> >>> ongoing with the
>> >>> SYNTEX and FREEDOM trials, together randomizing more than 4000
>> >>> patients to
>> >>> multivessel bypass surgery vs drug-eluting-stent placement."
>> >>>
>> >>>
>> >>> A moving target?
>> >>> But Taggart argues that this is simply moving the goalposts.
>> >>> "There have been
>> >>> hosts of studies showing surgery gives better results than
>> >>> stenting over the past
>> >>> 20 years, but interventional cardiologists keep on moving the
>> >>> target. When surgery
>> >>> was shown to be better than balloon angioplasty, they said, "Wait
>> >>> for the stent
>> >>> studies,' and now they are saying, 'Wait for the drug-eluting-
>> >>> stent studies.' " He
>> >>> also believes that the benefit of surgery has been underestimated
>> >>> in most studies,
>> >>> as patients with more severe disease were excluded. "Most studies
>> >>> comparing stents
>> >>> and surgery have enrolled patients with minimal disease, and a
>> >>> survival benefit is
>> >>> not going to show up in these patients. But these results have
>> >>> been rolled out to
>> >>> justify using stents in all patients. This is a complete
>> >>> distortion of the
>> >>> evidence," he commented to heartwire Taggart admits that,
>> >>> conceptually, stenting
>> >>> is obviously a popular option. "If you can achieve the same
>> >>> results without having
>> >>> to open the chest, of course this will be appealing. But the
>> >>> result is often not
>> >>> the same. And there is enormous pressure from the stent industry,
>> >>> which inevitably
>> >>> influences the situation." He points out that there is much more
>> >>> evidence in
>> >>> favor of surgery in patients with multivessel disease, with a
>> >>> survival benefit
>> >>> having been shown in this group, but there is still an increasing
>> >>> tendency for
>> >>> these patients to get stents. Taggart believes the fact that
>> >>> interventional
>> >>> cardiologists alone make the decision of whether stents or
>> surgery
>> >> should be used
>> >>> is the stumbling block here. "A significant number of patients
>> >>> don't even know
>> >>> that surgery is an option. Patients need to be given all the
>> >>> information on the
>> >>> options before the decision as to which way to go is made. "Yes,
>> >>> there is the
>> >>> supermarket convenience of inserting a stent while the patient is
>> >>> there in the
>> >>> cath lab rather than having to schedule another procedure time,
>> >>> but this is not a
>> >>> trivial decision. It is not reasonable for this decision to be
>> >>> made in a couple of
>> >>> minutes when the patent is lying on the cath-lab table. The
>> >>> different options need
>> >>> to be explained thoroughly, with input from both
>> >>> interventionalists and surgeons."
>> >>> Taggart says some lesions can be stented there and then in the
>> >>> cath lab and no
>> >>> one will argue—for example, single-vessel disease that is not
>> >>> proximal and for
>> >>> which stenting will not block a side branch. "But for more
>> >>> complicated
>> >>> single-vessel lesions and all multivessel disease, the treatment
>> >>> procedure should
>> >>> be separated from the diagnostic procedure and not undertaken
>> >>> until the patient
>> >>> has been informed of all the options," he concludes.
>> >>>
>> >>>
>> >>> Stop the "mine-is-better-than-yours" mentality
>> >>> Harrington comments that Taggart has some interesting ideas but
>> >>> that too much
>> >>> effort (and marketing money) is spent on the "mine-is-better-
>> than-
>> >>> yours" mentality
>> >>> and that instead all parties should work together to address the
>> >>> questions that
>> >>> will truly allow better healthcare. "Care for patients with
>> >>> obstructive CAD should
>> >>> be evidence based, and PCI and CABG should be thought of as
>> >>> complementary
>> >>> procedures with benefits (and risks) for different categories of
>> >>> patients based on
>> >>> CAD anatomy, LV function, other comorbid conditions, and patient
>> >>> values and
>> >>> preferences," he concludes.
>> >>>
>> >>>
>> >>>
>> >>> Sources
>> >>>
>> >>>
>> >>> Taggart DP. Coronary revascularization surgery is effective on
>> >>> clinical and
>> >>> economic grounds, but stenting does not seem to be cost
>> effective.
>> >>> BMJ 2007;
>> >>> 334:593-594. Aziz O, Rao C, Panesar SS et al. Meta-analysis of
>> >>> minimally
>> >>> invasive internal thoracic artery bypass versus percutaneous
>> >>> revascularisation for
>> >>> isolated lesions of the left anterior descending artery. BMJ
>> 2007;
>> >>> 334:617-621.
>> >>> Rao C, Aziz O, Panesar SS et al. Cost effectiveness analysis of
>> >>> minimally invasive
>> >>> internal thoracic artery bypass versus percutaneous
>> >>> revascularisation for isolated
>> >>> lesions of the left anterior descending artery. BMJ 2007;
>> >>> 334:621-624. Griffin
>> >>> SC, Barber JA, Manca A. Cost effectiveness of clinically
>> >>> appropriate decisions on
>> >>> alternative treatments for angina pectoris: prospective
>> >>> observational study. BMJ
>> >>> 2007; 334:624-628.
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>> Related links
>> >>>
>> >>>
>> >>> Stent or operate? New York Times revisits the age-old stenting vs
>> >>> surgery
>> >>> conundrum [Other News > MediaPulse; Feb 26, 2007]
>> >>>
>> >>> Stenting vs surgery: The surgeons' view
>> >>> [HeartWire > Other News; Sep 05, 2006]
>> >>>
>> >>> Three-year survival better with CABG than stenting for most
>> >>> multivessel CAD in
>> >>> registry analysis [HeartWire > Other News; May 25, 2005]
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>>
>> >>> Access to theheart.org is free, and is available only to
>> >>> healthcare professionals,
>> >>> media representatives, and medical librarians. To register as a
>> >>> user of
>> >>> theheart.org, click: http://www.theheart.org/<http://
>> >>> www.theheart.org/>
>> >>>
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