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Student Editorials

Coronary revascularisation

BMJ 2007; 334 doi: (Published 01 May 2007) Cite this as: BMJ 2007;334:0705172
  1. David P Taggart, professor of cardiovascular surgery1
  1. 1University of Oxford, Oxford OX3 9DU

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

On 24 March the BMJ published three studies dealing with revascularisation in ischaemic heart disease.13 Two of the studies compared the clinical effectiveness1 and cost effectiveness2 of revascularisation of isolated left anterior descending coronary disease by stenting or surgery, while the third examined 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 best 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 contraindicated.

Two studies in this issue, one a systematic review and meta-analysis,1 the other a …

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