Professionals

As shown in SYNTAX and other studies, CABG is associated with significantly lower rates of death, myocardial infarction (MI) and target vessel revascularization (TVR) vs. PCI.

A new study by the American Heart Association has shown that although the majority of clinical CardioVascular Disease (specifically Coronary Artery Disease and Stroke) events occur at middle and older ages, atherosclerosis begins in childhood and cardiovascular health among adolescents aged 12 to 19 years  is alarmingly poor. 

Cardiovascular health in adolescent males by race/ethnicity (aged 12–19 years):

In determining a treatment strategy for a patient with CAD, there are a variety of considerations that need to be made when selecting the appropriate treatment:

In 1995 Topol[1] first described what vascular surgeons have known for many years:

The pressure drop in a fluid flowing through a long cylindrical pipe such as a stenotic artery becomes functionally significant when the obstruction exceeds 70%, first described in the Poiseuille law in 1846[2].

As was stated in Topol's paper: “Accordingly, before the residual stenosis in an infarct vessel is addressed, there should be demonstration of either spontaneous or provocable signs of ischemia… clinicians and investigators rely excessively on angiography for clinical decision-making… Procedures should not be performed solely to improve the luminal appearance—so-called coronary “cosmetology".

This principle was tested with the PCI Fractional Flow Reserve FAME 1[3]&2[4] trials:

A few days ago I published an article about fatalities involving the new drug Dabigatran. This has resulted almost immediately in a letter from the Media Group Director of the PR company that handles advertizing for the pharmaceutical firm involved. I am glad to post it here:

"Just wanted to contact you with regard to your “Fatalities with Dabigatran and Warfarin Caused by Bleeding” article, and provide some further context about the analysis.

A FDA report presented at the 2013 American College of Cardiology (ACC) 2013 Scientific Sessions has suggested a much higher case fatality rate than that reported in other major clinical trials of the drug. For the study, reports of bleeding with dabigatran or warfarin submitted to the FDA between January 1, 2010, and June 30, 2012 were examined:

Adverse drug reactions relating to warfarin or dabigatran reported to FDA 

Five Things Physicians and Patients Should Question:

Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

Asymptomatic, low-risk patients account for up to 45 percent of unnecessary “screening.” Testing should be performed only when the following findings are present: diabetes in patients older than 40-years-old; peripheral arterial disease; or greater than 2 percent yearly risk for coronary heart disease events.

Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.

Cost-Effectiveness of PCI with Drug Eluting Stents versus Bypass Surgery for Patients with Diabetes and Multi-vessel Coronary Artery Disease: Results from the FREEDOM Trial.

Not only did patients with diabetes and multi-vessel CAD experience significantly better clinical outcomes after revascularization with CABG than PCI with a drug-eluting stent, according to results of the FREEDOM trial, based on lifetime projections, CABG was found to be more cost‐effective compared to DES‐PCI.

In the SYNTAX trial 1800 patients with previously untreated left-main or three-vessel disease were randomized to CABG or PCI.

As expected, differences in long-term outcomes of Coronary Artery Bypass Grafting vs. PCI, already present after year one, have continued to become more obvious during the next four years:

SYNTAX five-year results for patients with three-vessel disease:

The Society of Thoracic Surgeons’ risk model calculates the risk of operative mortality and morbidity of adult cardiac surgery on the basis of patient demographic and clinical variables. We have developed our own similar Cardiac Surgery Risk Assessment Calculator.