Coronary revascularisation

doi:10.1136/bmj.39154.552280.BE

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David P Taggart, professor of cardiovascular surgery (david.taggart@orh.nhs.uk)

University of Oxford, Oxford OX3 9DU

Surgery is effective on clinical and economic grounds, but stenting does not seem to be cost effective

This week, the BMJ publishes three studies dealing with revascularisation in ischaemic heart disease.1 2 3 Two of the studies compare the clinical effectiveness1 and cost effectiveness2 of revascularisation of isolated left anterior descending coronary disease by stenting or surgery, while the third examines the cost effectiveness of medical treatment, stenting, and surgery in multivessel disease.3 The 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.

Isolated left anterior descending coronary artery disease

Because the left anterior descending coronary artery supplies more myocardium than the circumflex or right coronary arteries, disease in its proximal portion carries a worse prognosis. When ischaemia is present, revascularisation improves survival4 even in asymptomatic patients.5 For more than two decades, the most durable and effective option for revascularisation has been an internal mammary artery graft which, unlike vein grafts, is almost immune to the development of atherosclerosis.6 This strategy significantly reduces the risk of death, subsequent myocardial infarction, recurrent angina, and the need for repeat intervention.6 However, because surgery has conventionally required a median sternotomy incision and cardiopulmonary bypass, many cardiologists have favoured the less invasive option of percutaneous revascularisation with stents, unless this is contraindicated by certain anatomical or pathological complexities.

Two studies in this issue, one a systematic review and meta-analysis,1 the other a cost effectiveness analysis,2 report that internal mammary artery …