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LETTERS: Stephen Westaby, Keith Channon, and Adrian Banning A sterile debate BMJ 2007; 335: 111 [Full text]

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To stent or not to stent? By no means a sterile debate.

Michael R Chester, John D Bridson, Clinical Ethicist NRAC   (26 July 2007)

To stent or not to stent? By no means a sterile debate. 26 July 2007
Michael R Chester, Consultant Cardiologist & Director NRAC National Refractory Angina Centre (NRAC), RLBUHT, LIverpool L14 3PE, John D Bridson, Clinical Ethicist NRAC Send response to journal: Re: To stent or not to stent? By no means a sterile debate.	The debate about the appropriateness of palliative revascularisation for stable angina will not easily be sterilised by an agreement between cardiologists and surgeons as to how the existing level of revascularisation activity should be shared. Westaby and colleagues are right to call for the inclusion of patient choice in the evidence base, but the sort of professional consensus they propose may only lead to a misleadingly limited choice between alternative modes of revascularisation. They deploy the argument that “less sanguine” patients will tend to opt for a less invasive approach which still leaves open the possibility of later coronary artery bypass graft surgery. We would argue that, on the same basis, low risk stable angina patients would also prefer a proper trial of conservative approaches, and retain the revascularisation option for later consideration, should the need arise. Thus the broader evidence base which Westaby et al., advocate must also include those patients who opt, or would opt, for approaches other than revascularisation. Our clinical experience (1,2) is consistent with the Healthcare Commission survey (3) which demonstrated unequivocally that adequate information is not routinely made available to patients undergoing revascularisation, suggesting that the recent important changes in professional and consent guidelines have yet to be properly implemented in cardiology and cardiac surgery consent practice (4,5). Two major manufacturers in the US recently reported a more than 40% slump in drug eluting stent sales this year following the publication of the Courage, Griffin and late stent thrombosis data (6,7,8). Can this possibly reflect a less sanguine attitude towards the risks of transiently effective percutaneous palliative revascularisation on the part of the ‘prudent’ North American patient ? References 1 Bridson J, Hammond C, Leach A, Chester MR. Making consent patient centred BMJ 2003;327;1159-1161 2 Moore RKG, Groves DG, Bridson J D, Grayson AD, Wong H, Leach A, Lewin RJP, Chester MR. A Brief Cognitive-Behavioral Intervention Reduces Hospital Admissions in Refractory Angina Patients J Pain Symptom Manage. 2007 Mar;33(3):310-316 3 Heart patient survey shows too many people are leaving hospital without aftercare and advice June 2005. http://www.healthcarecommission.org.uk/newsandevents/pressreleases.cfm/widCall1/customWidgets.content_view_1/cit_id/1998 4 http://www.gmc-uk.org/guidance/good_medical_practice/index.asp (accessed 20 July 2007) 5 Parliamentary and Health Service Ombudsman, and the President of the Society of Cardiothoracic Surgeons of Great Britain and Ireland a joint report. ‘Consent in cardiac surgery: a good practice guide to agreeing and recording consent’ May 2005 www.ombudsman.org.uk/improving_services/best_practice/cardiac05/index.html 6 Boden et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007; 356:1503-1516 7 Griffin SC, Barber JA, Manca A, Sculpher MJ, Thomson SG, et al. Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study. BMJ 2007;334:624-8. (24 March.) 8 Pfisterer M,et al., on behalf of BASKET-LATE Investigators. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare- metal stents. J Am Coll Cardiol. 2006 Dec 19;48(12):2584-91 Competing interests: Dr Chester provides consultancy advice to PBC/PCT commissioning groups who wish to reduce the overperformance of unnecessary palliative revascularisation procedures