Surgery is the best intervention for severe coronary artery disease
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7494.785 (Published 31 March 2005) Cite this as: BMJ 2005;330:785
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This spat as to the best treatment of this extensive and expensive
disease will only convince governments that clinicians are not to be
trusted in their assessment of treatments. Thus,in England it is only a
matter of time before the management of coronary heart disease will be
determined by NICE(National Institute of Cinical Excellence) and dictated
by the hospital chief executive. This extremely important editorial on a
multidisciplinary subject should have been authored jointly by a
cardiologist and a cardiac surgeon. The political naivety of clinicans
raises its head once again
Competing interests:
None declared
Competing interests: No competing interests
Whilst we are in agreement with many of Professor Taggart's comments
we feel that a few points need to be addressed to the non-cardiological
readership.
Professor Taggart criticises the applicability of research regarding
percutaneous coronary intervention (PCI) versus coronary artery bypass
grafting (CABG). Yet the key reference demonstrating improved survival in
CABG versus medical therapy was based upon data gathered between 1972 and
19841. Medical therapy did not include statins or ACE inhibitors and anti-
platelet drug use was <10%. Furthermore, the subgroup with left main
disease included only 150 patients with 39 deaths and on this basis
hundreds of thousands of people have been put forward for surgery on
prognostic grounds.
Comparison between CABG and PCI in patients with multi-vessel
coronary disease has consistently demonstrated equivalent mortality but a
higher rate of repeat revascularisation in the PCI group. As CABG and PCI
techniques have advanced, trials have included patients with more complex
disease but the gap between the two procedures has narrowed.
We agree that symptomatic patients with patterns of disease including
the left main, complex bifurcations and with multiple chronic occlusions,
particularly in diabetics, are well served by surgical revascularisation.
However, to criticise the angiographic re-stenosis rates following
coronary stenting is to forget that up to 15% of saphenous vein grafts
will have occluded before the surgical patient leaves hospital2.
Real world data are collected in the UK by the british cardiac
intervention society (BCIS), and of the 53,261 PCI procedures performed in
2003, only 1,097 (2.1%) were performed for multivessel disease with
chronic total occlusion. Cardiologists have nevertheless become skilled
in selecting appropriate patients for such treatment and the hospital
mortality for this group was 0.04%.
The recently reported ARTS II cohort treated percutaneously with drug
eluting stents demonstrated no difference in major adverse or cardiac
events and less need for repeat percutaneous intervention (5.4%) compared
to previous trials. We await with interest the results of the randomised
SYNTAX trial which should help provide further answers for patients with
multivessel disease.
Professor Taggart's suggestion that cardiologists coax patients
towards PCI to avoid an operation is unfounded. Individual treatment
decisions are not based simply on the number of vessels with important
narrowings and we know of no cardiologists systematically denying their
patients a surgical opinion.
1Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, et
al. Effect of coronary artery bypass graft surgery on survival: overview
of 10-year results from randomised trials by the Coronary Artery Bypass
Graft Surgery Trialists Collaboration. Lancet 1994;344:563-70.
2 Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T,
Doherty J, Read R, Chesler E, Sako Y, et al. Improvement in early
saphenous vein graft patency after coronary artery bypass surgery with
antiplatelet therapy: results of a Veterans Administration Cooperative
Study. Circulation. 1988 Jun;77(6):1324-32.
Competing interests:
Hugh Griffiths performs PCI
Competing interests: No competing interests
Dear Editor,
We congratulate David Taggart on successfully writing a very
controversial article (Taggart DP. Current controversies. Surgery is the
best intervention for severe coronary artery disease BMJ 2005; 330; 785-
6).
Sadly, the wider public health context is completely ignored.
In fact, the population impact of cardiac surgery and angioplasty is
surprisingly small. But why is that?
Coronary heart disease (CHD) typifies the iceberg of disease
principle. Almost 3 million patients suffer from CHD in the UK.[1]Yet
barely 60,000 patients undergo revascularisation each year.
Meanwhile, between 1981 and 2000, CHD mortality rates in England and
Wales fell by 62% in men and 45% in women aged 25-84. This represented
68,230 fewer deaths in 2000. Some 58% of this mortality fall was
attributed to population risk factor reductions, principally smoking, also
blood pressure and cholesterol. [2]
Treatments in individual patients accounted for some 42% of the
mortality fall. However, the contribution from revascularisation was only
4% [2], much as in the USA [3]. This was a disappointingly small
contribution, particularly when considering the large financial and
political resources being consumed. [6]
We suggest those resources might be better spent on prevention [4,5].
Yours sincerely
Simon Capewell, MD*
Julia Alison Critchley, DPhil #
Belgin Ünal, MD, MPH **
Robin Ireland BA##
*Department of Public Health,
University of Liverpool, L69 3GB, UK.
#Liverpool School of Tropical Medicine & Hygiene.
**Department of Public Health, Dokuz Eylul University School of
Medicine, Izmir, Turkey.
## Heart of Mersey, Burlington House, Liverpool 21.
References
1. British Heart Foundation statistics. www.heartstats.org (accessed
24/03/05).
2. Unal B, Critchley JA, Capewell S. Explaining The Decline In Coronary
Heart Disease Mortality In England And Wales Between 1981 And 2000.
Circulation 2004, 109 (9) 1101-7.
3. Doliszny KM, Luepker RV, Burke GL, Pryor DB, Blackburn H. Estimated
contribution of coronary artery bypass graft surgery to the decline in
coronary heart disease mortality: the Minnesota Heart Survey. J Am Coll
Cardiol 1994; 24(1):95-103.
4. Heart of Mersey Primary Prevention Programme www.heartofmersey.org.uk/
(24/03/05).
5. M Kelly & S Capewell. Relative contributions of changes in risk
factors and treatment to the reduction in coronary heart disease
mortality. NHS Health Development Agency. Briefing Paper. HDA, London,
2004.
http://www.hda-online.org.uk/Documents/CHD_Briefing_nov_04.pdf
6. CHD National Service Framework - Leading the way. Fifth anniversary
progress report. http://www.dh.gov.uk/assetRoot/04/10/52/82/04105282.pdf
(DH 04/03/05).
Competing interests:
None declared
Competing interests: No competing interests
Surgery is the best intervention for severe coronary artery disease
Editor- Taggart’s concern (1) over the expansion of percutaneous
coronary intervention (PCI) apparently at the expense of coronary artery
bypass grafting (CABG), is misplaced and unfortunately continues to
perpetuate the myth that these two modalities exist in opposition. This
may exacerbated by the BMJ’s choice of this article to provide a
provocative headline for the front cover.
The majority of PCI activity in this country continues to be single
vessel intervention (2). This follows the tendency for more patients to be
investigated with angiography at an earlier stage in their disease –
particularly in the context of an acute coronary syndrome. It is this
trend that is largely responsible for the increase in PCI, rather than a
wholesale transfer of cases from surgeon to interventionist. Furthermore,
CABG during unstable coronary episodes incorporates increased risk, as
does an aging population base associated with more co morbidity. As media
and public scrutiny continues to focus on surgical outcomes, this also
makes PCI a preferable option even acknowledging the presence of severe
multivessel disease.
We agree with the underlying sentiment of Taggart’s article. The
choice of revascularisation for an individual patient should not simply be
based on the anatomical data but emerge from a joint discussion between
surgeons and interventionists, that incorporates all relevant information.
We use such a multidisciplinary forum for elective patients, and also
apply this approach to unstable or high risk cases when either CABG or PCI
are seen as equally possible treatments.
Michael S. Norell, Interventional Cardiologist
Saib S. Khogali, Interventional Cardiologist
James M. Cotton, Interventional Cardiologist
Michael R. Cusack, Interventional Cardiologist
The Heart and Lung Centre,
Wolverhampton,
WV10 0QP
Michael.norell@rwh-tr.nhs.uk
Competing interests: None declared
1. Taggart DP. Surgery is the best intervention for severe coronary
artery disease. BMJ 2005;330:785-6
2. British Cardiovascular Intervention Society audit returns for 2003.
www.bcis.org.uk
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Taggart (1) has argued very well for the superiority of bypass
grafting over angioplasty. However an impediment to accepting his
conclusions is the fact that he, like me, is a cardiac surgeon. Our
livelihood depends upon bypass surgery. I have little doubt that his
article will evoke a response from a cardiologist questioning his
interpretation. However as their livelihood is dependent upon angioplasty
the same "doubt" applies to their viewpoint.
Currently there is a wide range of available treatment options for
coronary artery disease delivered by different specialists. Currently the
"gatekeepers" are the cardiologists who perform diagnostic angiography.
Unsurprisingly many cardiac surgeons feel this introduces a bias into
deciding upon optimum treatment. The published results from comparative
trials have not given a clear answer as to the relative superiority of
surgery or angioplasty. Their interpretation has been dependent upon which
specialist is looking at them. Also all the published trials are
"historical" in that by the time they are published new techniques have
been introduced so that their results may no longer be relevant.
So who should decide upon individual treatment? It has been suggested
(2) that the ideal person would be a "coronary artery disease specialist."
This would be an individual who is skilled in all the available techniques
i.e. a cardiac surgeon who can perform angioplasty or a cardiologist
capable of coronary surgery. There would be one in each unit who could
then channel the patients most appropriately to the other specialists.
Such individuals do not as yet exist. However given the prevalence of
coronary artery disease and the many forms of treatment available such a
development would be both logical and beneficial. Failing this it is
unlikely that the argument as to the best method for treating coronary
artery disease will ever be resolved.
Lindsay John
1) Taggart D.P. Surgery is the best intervention for severe coronary
artery disease. BMJ 2005;330:785-6 (2 April).
2) John L.C.H. Cardiac revascularisation - a need for independent
decision-makers. J.Royal Soc.Med. 2005;98:1-2.
Competing interests:
I regularly perform coronary artery surgery.
Competing interests: No competing interests
Congratulations Professor on a good article.
Your article is a shot in the arm for young doctors
intending to pursue a career in cardiac surgery.
I however hope fervently that training oppurtunities
in cardiac surgery improve for good sooner than later.
Kindest Regards
Dr Alva
Competing interests:
None declared
Competing interests: No competing interests
Congratulations to my colleague Professor David Taggart for
highlighting the important issue regarding the management of cardiac
disease.
The consent process needs to be more transparent and physician
behaviour must become more participatory. The establishment of multi-
disciplinary teams has been demonstrated to facilitate decision processes
and remove natural heuristics or biases. The physician and patient bring
with them risk aversive behaviours and actuarial summation of the evidence
is commonly lacking. (See works by Gigerenzer and nobel laureate
Kahneman). Indeed some authors such as Arthur L Kaplan question whether
it is ethical for the doctor taking consent to be the same one offering
the interventional therapy. “Framing” and cognitive biases will continue
persist whilst a single person acts as “a gatekeeper” to treatment. I
believe our patient / customer does not have all the information necessary
to make a fully informed consent to a percutaneous intervention.
Competing interests:
None declared
Competing interests: No competing interests
there is no such "dogma" that by-pass or pci is the best. each case
needs to be individualised for the special needs of the patient. for
instance, in india, economic costs weigh heavily in favor of bypass
surgery. however, when finance is not a constraint, many people opt for
multivessel pci with multiple des implants provided the anatomy of the
coronaries warrant such. previously, diabetics with multivessel disease
were advised across board to undergo by-pass. with the impressive results
of des implants, with zero rate restenosis at least in the short term,
this practice is being increasingly challenged.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor :
Since both CABG and PCI target only the most apparent pathology based
on angiographic imagings,this approach may ignore the superb potential for
reversing Endothelial Dysfunction allover the vascular tree, including
coronaries.
It has been proven in the US through Dr.Dean Ornish, that a strict dietary
system and life style modification( you may add to it statins, ACE
inhibitors) is able ro reverse Atherosclerotic plaques.
Mohamed Noshi,MD,FACP
Consultant ,Internal Medicine
Fort Lauderdale FL 33062
USA
Competing interests:
None declared
Competing interests: No competing interests
Re: Endothelial Dysfunction as target for treatment in multivessel Coronary Artery Disease
The recently published data that Coronary Angioplasty is not superior
to medical treatment in stable patients with coronary artery disease
further emphasizes this point.
Competing interests:
None declared
Competing interests: No competing interests