Peter K. Smith, MD The Annals of Thoracic Surgery

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Presentation transcript:

Treatment Selection for Coronary Artery Disease: The Collision of a Belief System with Evidence Peter K. Smith, MD The Annals of Thoracic Surgery Volume 87, Issue 5, Pages 1328-1331 (May 2009) DOI: 10.1016/j.athoracsur.2009.03.026 Copyright © 2009 The Society of Thoracic Surgeons and The American Association for Thoracic Surgery Terms and Conditions

Fig 1 Adjusted long-term actuarial survival for 18,481 Duke University patients (1986 to 2003) with severe coronary artery disease treated with medical therapy (black line) compared with revascularization by percutaneous coronary intervention or coronary artery bypass grafting (red line). The Annals of Thoracic Surgery 2009 87, 1328-1331DOI: (10.1016/j.athoracsur.2009.03.026) Copyright © 2009 The Society of Thoracic Surgeons and The American Association for Thoracic Surgery Terms and Conditions

Fig 2 Appropriateness criteria result for percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with coronary artery disease extent considered sufficient for appropriateness of revascularization, stratified by extent of disease and association of diabetes or impaired left ventricular function. (A = Appropriate, U = Uncertain, I = Inappropriate; LAD = left anterior descending artery; LVEF = left ventricular ejection fraction.) This figure is reproduced, with permission, from “Appropriateness Criteria for Coronary Revascularization” by Patel MR, et al. J Am Coll Cardiol 2009;53:545. Copyright 2009 American College of Cardiology Foundation. The Annals of Thoracic Surgery 2009 87, 1328-1331DOI: (10.1016/j.athoracsur.2009.03.026) Copyright © 2009 The Society of Thoracic Surgeons and The American Association for Thoracic Surgery Terms and Conditions

Fig 3 Changing patterns of initial treatment selection among medical therapy (MED, yellow line), percutaneous coronary intervention (PCI, red line), and coronary artery bypass grafting (CABG, blue line) from 2000 to 2008 at Duke University in 10,149 patients. Decline in CABG selection is seen after drug-eluting stent (DES) introduction, with a corresponding increase in PCI. The presentation of DES acute thrombosis as a concern resulted in a decline in PCI but an increase in medical therapy selection rather than CABG. Reconciliation occurred through observational analysis and expert opinion that indefinite dual antiplatelet therapy and decreasing DES use may limit acute stent thrombosis. With the presentation of the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, PCI recommendations have returned to 2004 levels. The Annals of Thoracic Surgery 2009 87, 1328-1331DOI: (10.1016/j.athoracsur.2009.03.026) Copyright © 2009 The Society of Thoracic Surgeons and The American Association for Thoracic Surgery Terms and Conditions