[HSF] PCI Vs CABG - not all about evidence

Mon Dec 31 08:39:27 EST 2007

There is a reverse gradient of mortality benefit from the proximal LAD lesion to the transplant of the endstage ventricle. I'll start with the much less static time-place benefit of the Lad repair to get the potentially much greater life long preservation of the LV benefit. Mark is not completely off in comparing life long Plavix (and interventions) to CAB. 
There is a world of difference between good evidence of no benefit and no good evidence of benefit in EBM.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Sunday, December 30, 2007 11:53:58 PM
Subject: RE: [HSF] PCI Vs CABG - not all about evidence

Am I missing something here? The more responses I see saying they would have a CABG for scenario one the more crazy I think i must be getting - I have read Eds original post at least 10 times to see if I missed something and still cannot get it. 

Are we really saying we would have a CABG for single vessel single lesion LAD disease in a non-diabetic patient with presumably good LV function not even on optimal medical therapy? No nitrates, no calcium blockers, just ACEI and Betablockers which are not even in antianginal doses? I think I need enlightening here as to why those who opt for CABG are doing so - last time I checked I was not aware of any evidence of survival benefit of surgery over medical therapy in this situation, talk less angioplasty so are we saying we would have a CABG to control our symptoms when we have not even tried medicines or are there now data showing benefit of surgery for this scenario? Or are we falling guilty of the occulostent reflex we accuse the cardiologists of, except now an occulo-lima reflex. 

I would say for this patient there is little or no evidence to recommend either CABG or PCI and certainly if one had to choose there cannot be any evidence that either is beneficial over the other - surely this has to be a joke? Even the indication for a cath here is dubious. The goal of therapy here is to reduce symptoms and not to prolong life (as there is no evidence that any therapy does that) and as Ed has shown a simple balloon can achieve that for decades - for many others a good dose of a nitrate and betablockers and life-style modification with some aspirin and statins to top it up is more than enough to keep this state of affairs dormant for years. Are we now so desperate that we are creating surgical diseases where none exists?

Ani

> From: donross at bigpond.com> Subject: Re: [HSF] PCI Vs CABG - not all about evidence> Date: Mon, 31 Dec 2007 12:07:09 +1100> To: OpenHeart-L at lists.hsforum.com> CC: > > I asked one of our interventional cards what he would have in #1> He waned lma to LAD. I then asked about a bare metal stent which > presumably would have a gentle failure mode.> But he surprised me by stating that they can , but at a lower > frequency to coated stents, also thrombose catastrophically> Don> On 31/12/2007, at 10:49 AM, Tea Acuff wrote:> > > I probably would agree with your own #2, but consider what I say > > about #1.> >> > I don't believe what we name as equals are equals, so I would wish > > to look at the lesion if I weren't in the middle of a heart attack. > > I think it makes prefectly good sense to PCI technically easy > > lesions. The data would support this also (or so I read it). So > > does your family experience. If the interventionalist (who is now > > left out
 of the decision) has any doubts or reservations then > > certainly CAB with LIMA. I doubt I would ask for a DES.> >> > tea> >> >> > ----- Original Message ----> > From: Edward Bender <ebender001 at charter.net>> > To: OpenHeart-L at lists.hsforum.com> > Sent: Sunday, December 30, 2007 5:06:08 PM> > Subject: Re: [HSF] PCI Vs CABG - not all about evidence> >> > Answering my own questions:> > 1. Tainted by my family history since my father had PTCA by Grunzig> > in 1981 at Emery U. He developed recurrent angina 20 years later and> > got re-cathed, revealing normal appearing LAD (previous PTCA using> > Grunzig balloon) but a tight mid RCA which was stented.> >> > 2. I would choose LIMA to LAD and good quality SVG to RCA. I am> > worried about recurrent disease or some other process requiring re-> > sternotomy. In my hands, re-entry is easier with SVG to RCA than > > RIMA.> >> > Ed Bender, MD> >> >> > On Dec 30, 2007, at 4:50 PM, tdmartin2000 at aol.com wrote:> >> >>
 Ed> >> I would have CAB surgery.> >> Tom Martn> >>> >>> >> -----Original Message-----> >> From: Edward Bender <ebender001 at charter.net>> >> To: OpenHeart-L at lists.hsforum.com> >> Sent: Sun, 30 Dec 2007 4:16 pm> >> Subject: Re: [HSF] PCI Vs CABG - not all about evidence> >>> >>> >> I would like to ask the forum members what choice they would make> >> for themselves in the following two circumstances:?> >> ?> >> ?You are a 62 year old heart surgeon and getting chest pain with> >> moderate exertion (class 2-3 angina) already on meds for> >> hypertension (beta blocker/ACEI). You go to the cardiologist whom> >> you think has the best clinical judgement and that cardiologist is> >> not an interventionalist but does do caths (so if you need PCI a> >> referral will happen). You get cathed and:?> >> ?> >> 1) you have a 95% proximal LAD stenosis at the first septal> >> perforator but not a branch lesion. Surgery or PCI? What graft or> >> what intervention??> >> ?>
 >> 2) you have the same lesion as #1, but you also have a 70% mid> >> dominant RCA stenosis. Same questions.?> >> ?> >> In our minds we probably are thinking about early and late hazard> >> curves and Eugene Blackstone in addition to the what and where of> >> treatment options.?> >> ?> >> Just curious.?> >> ?> >> Ed Bender, MD?> >> ?> >> On Dec 30, 2007, at 2:05 PM, Ani Anyanwu wrote:?> >> ?> >>> 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 c> >> onned 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 solu> >> tion 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> >>>>> -----------------------------------------?> >>> _________________________________________________________________?> >>> Free games, great prizes - get gaming at Gamesbox.?> >>> http://>> >>> www> >>> .searchgamesbox.com_______________________________________________?> >>> OpenHeart-L mailing list?> >>> ?> >>> Send postings to:?> >>>
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