[HSF] PCI Vs CABG - not all about evidence

Sun Dec 30 12:45:41 EST 2007

Well said again, Ani. 
As I have tried to get us to visualize in the concrete terms of a model, patients are the mostly forgotten (dance) partner in our practice and the absolutely forgotten partner in our evidence. It is not unlike the open dances in high school. If we wait for someone to notice how great we are, and treat them only in terms of our personal world when we finally get a dance, we don't get many dances...even if we are the "best" ...whatever that means in the scheme of things.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Sunday, December 30, 2007 2:05:48 PM
Subject: [HSF] PCI Vs CABG - not all about evidence

Hal

A lot of the drive for PCI comes from the patient themselves. Patients do not want surgery. Unless we reinvent ourselves we will continue to lose this 'battle' with PCI. Taggart's logic is flawed because evidence is not the main driving factor as to how patients are revascularised (else many more would have CABG). How many other examples do you know where an inferior therapy is more used than a more effective one? There are reasons why this is the case with PCI. Cary just talked about his colleague - an established coronary surgeon - who opted for PCI over CABG for his LAD disease and I know of two rather prominent London surgeons that have done the same. One of my cardiologists who is really pro-CABG had his mum come in with angina and she left with stents in RCA and Cx. A senior  doctor in our hospital dropped dead after an LAD DE stent thrombosed two years ago. There are numerous senior doctors who opt for PCI and we cannot say they were also conned
 on the cath table. Surely all these doctors know or have access to the data and are not being misinformed by cardiologists. Even well informed patients will chose PCI over surgery in many instances.

Indeed in the last 3 months I have had two patients - one with left main stenosis and another three vessel disease - referred (by an interventional cardiologist) for surgery and they both asked me cant this be done by angioplasty? I explained the risks and benefits of surgery to both patients. One was a Child B cirrhotic and he was rightly concerned about the risk of surgery. Both patients asked for a consult with an interventional cardiologist (who to be fair told them both that he advises surgery over PCI) and they both  weighed pros and cons chose to have PCI (and this was not on same day as diagnostic cath).

We focus on the wrong thing if we keep selling this 'CABG is better than PCI' message. Everyone knows CABG is better. The reality is humans are so constituted that they are more concerned with immediate loss (death, disruption and pain from surgery) than they are of future benefit (longer life free of intervention) which is why we smoke for example. Most given the option - even cardiac surgeons - would prefer to avoid an operation even if they may be compromising their long term outcomes. I remember even as a child (11 year old) I was in tropical africa and bitten by a stray dog. I never mentioned this to my parents till few days later because i did not want to receive the mandatory passive rabies prophylaxis required for dog bites (which then consisted of daily intraperitoneal injections for 21 days) - i decided i would rather risk death than go through the ordeal of injections. Similarly I have refused immunizations and been prepared to suffer the
 consequences of deadly infection because I have a phobia for needles. So as long as PCI involves a prick to the groin and surgery a general anesthetic with a large painful incision then *many* patients will opt for PCI. That they come back in 6, 12 or 60 months for repeat revascularization or that they die later, is in the future and the future will take care of itself. 

If we want a CABG rennaisance we don't need surgeons standing in meetings spurring animosity between surgeons and cardiologists and showing slides and slides as to how CABG is better than PCI. We have heard the message of Taggart and many before him for decades - those messages have done nothing and will do nothing to reverse the imbalance between PCI and surgery. We need to refocus ourselves away from evidence and back to ways we can make CABG more appealing, more effective, less traumatic and more acceptable to patients. As I often bring up on HSF for example (which whenever I raise it the response is a controlled silence) how could we all be putting in vein grafts in people and yet criticise cardiologists for dishing out an inferior revascularisation therapy? Walking into our cath lab there is hardly a day I do not see a diseased vein graft on the monitor being intervened upon - how then can we seriously expect them to believe we have the solution for
 CAD. The future has to be more collaboration rather than animosity - as strange as it might sound, we all want the best for the patient (even if we interpret the best in different ways).

Evidence is only one of many factors that comes in consideration when patients or doctors chose therapy...there are several others, and in the revascularization debate these others have proven more overriding.

Ani

> From: Hgrmd at aol.com> Date: Sun, 30 Dec 2007 13:57:52 -0500> Subject: Re: [HSF] The Great con....> To: OpenHeart-L at lists.hsforum.com> CC: > > Michael,> I beg to differ. Stents have been terrible for our business. That is > unequivocally reflected by the declining numbers of stand alone CABG's done in > the U.S. In spite of the fact that there is nothing to back it in the > literature, cardiologists continue to restent recurrent stenoses as well as > multivessel disease. I have heard Taggart address this at the last STS as well as > the ACTS meeting. One of his main points is that the interventional > cardiologist usually makes the decision on the table with minimal input from a sedated > patient, and without the advice of the surgeon. I can't tell you how many > times I've heard the interventionalist tell me the patient didn't want surgery > as he gamely justified the reason for a multivessel PCI. The only solution > is to stop cath/possible PCI on
 stable patients. These stable patients should > have the diagnostic cath, be presented the options by the cardiologist as > well as the surgeon, and then proceed from there.> > Hal> > > > **************************************See AOL's top rated recipes > (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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