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J Thorac Cardiovasc Surg 2009;137:1050-1053
© 2009 The American Association for Thoracic Surgery

Editorial

Treatment selection for coronary artery disease: The collision of a belief system with evidence

Division of Thoracic Surgery, Duke University, Durham, North Carolina

Received for publication March 5, 2009; revisions received March 9, 2009; accepted for publication March 10, 2009.

^_* Address correspondence to Peter K. Smith, MD, Division of Thoracic Surgery, Duke University, PO Box 3442, 4532 Hosp South, Durham, NC 27710. (Email: smith058@mc.duke.edu).

The first 300 words of the full text of this article appear below.

Development of interventional therapy for coronary artery disease (CAD) has unquestionably improved and prolonged the lives of millions, but the complex manifestations and presentations of the disease have confounded easy decision making to develop "the best treatment" option for each patient. Two important papers, recently published, support coronary artery bypass grafting (CABG) as the treatment of choice for patients with advanced CAD (3-vessel disease or left main coronary disease) compared with percutaneous coronary intervention (PCI).

The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial¹ demonstrated a significant reduction in the composite rate of major adverse cardiovascular event (MACE) end point, defined as mortality, myocardial infarction, stroke, or reintervention, for CABG compared with PCI. The "Appropriateness Criteria for Coronary Revascularization," sponsored by the American College of Cardiology Foundation, assembled experts to create 180 different clinical vignettes to represent a cross-section of contemporary practice as encountered by working cardiologists and surgeons.^2,3 For 3-vessel disease, CABG was rated appropriate, and PCI rated uncertain. For left main coronary disease, CABG was rated appropriate, and PCI was rated inappropriate.

Despite these findings, it is apparent that their translation into practice is being heavily influenced by various stakeholders whose belief systems are unfulfilled by the evidence. The purpose of this editorial is to clarify the body of evidence as it exists today so that all stakeholders are held accountable to the primary stakeholders, our patients.

This is only reasonable, because 3-three vessel CAD afflicts 23% of patients found to have significant coronary disease at diagnostic cardiac catheterization (unpublished data from 10,149 patients in the Duke Cardiovascular Disease Databank, 2000 to 2008). Long-term follow-up of patients who received medical treatment shows survival at 5, 10, and 15 years of only 61%, 38%, and 22%, respectively (Fig 1). When patients were treated by PCI . . . [Full Text of this Article]