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Letters to the Editor

Medical, angioplasty or surgery for stable coronary artery disease; do we have an answer !!!

Tufts School of Medicine, Caritas St Elizabeth Medical Center, 736 Cambridge Street, Brighton MA 02135, USA

Received 9 March 2008; accepted 21 May 2008.

^_* Corresponding author. Address: Department of Internal Medicine, 736 Cambridge Street, Caritas St Elizabeth Medical Center/Tufts School of Medicine, Brighton MA 02135, USA. Tel.: +1 617 734 1300; fax: +1 617 562 7797. (Email: ganeshathappan{at}gmail.com).

Key Words: Revascularization • Angioplasty • CABG

The results of the 5-year follow-up of the MASS trial by Lopes et al. [1] describing the ‘impact of number of diseased vessels on clinical outcome’ was well written and read with great interest. It has again added fuel to the existing debate of coronary artery bypass grafting (CABG) versus percutaneous intervention (PCI) with stenting versus medical management in stable coronary artery disease and brings out some important points for discussion.

1. It is interesting to note that none of the randomized controlled trials comparing CABG versus PCI with stent in multivessel disease including the present one, have found a superior advantage of CABG in survival over 5 years [2,3]. Therefore it would be important to know if there were any significant increases in ‘revascularization procedures’ in the PCI with stent versus CABG arm stratified by the number of vessel disease. The authors have provided data comparing each treatment arm with vessel involvement and comparing composite endpoints of mortality, MI or refractory angina requiring revascularization but not specifically for revascularization in the same subgroup. [SVD – 10.7% with PCI vs 8.8% with CABG, 2VD – 14% revascularization with PCI vs 7.5% in CABG, 3VD – 9.5% with PCI vs 8.9%with CABG, were these significant?]. This would be important as increased revascularization if observed in the PCI arm versus CABG for a specific group (3VD or 2VD), would mean increased health costs at same survival benefits.

2. For reasons above and others it would be more informative if the patient characteristics assigned to treatment by CABG, PCI or medical had been provided for each group. This would help to rule out selection bias.

3. There was no increase in myocardial infarction (MI) in the 3VD group and the patients were significantly older. The cause of death in these patients was probably due to comorbid conditions and would be worth mentioning as it would help us to target treatment towards these factors in the face of better revascularization outcomes.

4. The extent of aggressive lipid management in the medically treatment group too is unclear. The COURAGE [4] trial showed no benefit of PCI with aggressive medical management over aggressive lipid management alone. The LDL levels achieved in the medically treated patients would help us compare the benefits of this treatment line compared to CABG or PCI.

5. We would like to point out an error in the units used for cholesterol levels in these patients. They have been mentioned as mmol/l but should be mg/dl.

References

1. Lopes NH, Paulitsch F da S, Gois AF, Periera AC, Stolf NA, Dallan LO, Ramirez JAF, Hueb WA. Impact of number of vessel disease on outcome of patients with stable coronary artery disease: 5-year follow-up of the medical, angioplasty, and bypass surgery study (MASS). Eur J Cardiothorac Surg 2008;33:349-354.[Abstract/Free Full Text]
2. Serruys PW, Ong ATL, Van Herwerden LA, Sousa JE, Jatene A, Bonnier JJRM, Schonberger JPMA, Buller N, Bonser R, Disco C, Backx B, Hugenholtz PG, Firth BG, Unger F. Five year outcome after coronary stenting versus bypass surgery for the treatment of multivessel disease. J Am Coll Cardiol 2005;46(4):575-581.[Abstract/Free Full Text]
3. Rodriguez AE, Baldi J, Periera CF, Navia J, Alemparte MR, Delacasa A, Vigo F, Vogel D, O’Neill W, Palacios IF. Five-year follow-up of the Argentine randomized controlled trial of coronary angioplasty with stenting versus coronary bypass surgery with multiple vessel disease. J Am Coll Cardiol 2005;46(4):582-588.[Abstract/Free Full Text]
4. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Caperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini J, Weintraub WS. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516.[Abstract/Free Full Text]

This article has been cited by other articles:

				N. Lopes, F. S. Paulitsch, and W. Hueb Reply to Athappan and Subramanian Eur. J. Cardiothorac. Surg., September 1, 2008; 34(3): 703 - 703. [Full Text] [PDF]

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