1. Section 5: Intervention and drug therapy
Progression of atherosclerosis observed in 307 repeat angiographies post-CABG
Content Points:
van Brussel et al followed 428 patients who had undergone isolated venous CABG.32 In 189 patients, a total of 307 repeat angiograms were conducted because of recurrent signs of ischemia.
As shown on the slide, progression in the native coronary circulation only was observed in 38 angiograms; progression in the native coronary circulation in combination with progression in venous graft was observed in 66 angiograms; and progression in venous graft only was observed in 135 angiograms. No progression was observed in 68 angiograms.
It was also found that 40% of documented progression occurred distal to the site of vein graft insertion. To the investigators this suggested that patients with more extensive disease at the time of operation progressed more rapidly post-CABG.
The investigators concluded that even after complete revascularization, long-term clinical outcome might be determined by progression in native coronary arteries.
Prevention of disease progression following revascularization is clearly an important goal.

2. Clinical studies summary: Angiography in infarct-related artery
Content Points:
In a review of coronary plaque disruption, Falk et al31 collated data from studies by Ambrose et al,33 Little et al,34 Nobuyoshi et al,35 and Giroud et al.36
The slide summarizes the number of patients with MI caused by rupture of plaques causing either > 70%, 50%-70%, or < 50% stenosis. In 68% of cases, the coronary event was caused by plaques causing < 50% stenosis.

3. PCI vs medical Rx for angina
Content Points:
The second Randomized Intervention Treatment of Angina (RITA-2) trial was a randomized comparison of the effects of PCI (an accompanying stent was inserted in 9% of cases) and conservative medical care.10
In slide 8, it was pointed out that PCI was more effective than medical therapy in relieving angina. However, as shown here, during follow-up the rate of death or MI was 6.6% and 3.3% in the PCI and medical groups, respectively (P = 0.02). The excess risk in the PCI group was mainly due to a higher incidence of procedure-related nonfatal MI and occurred within 3 months of randomization.
While the absolute risk was low in both groups, these data are consistent with evidence that MI may not be due to flow-limiting stenoses.

4. Complementary effect of major therapies on 3 vital Rx goals
Content Points:
In summary, while CABG and PCI have been shown to relieve symptoms, they have not been shown to prevent MI.10,22,37 However, data from the Asymptomatic Cardiac Ischemia Pilot (ACIP) study suggest that CABG and PCI may prolong life in some subsets.38
In contrast, lipid lowering (principally with statins and diet) has been shown to positively affect all 3 goals.37,39,40

5. Coronary artery disease: Should plaque stabilization be a primary goal?
Content Points:
The finding that revascularization has a positive effect on symptoms but not on long-term outcome has prompted some researchers to question the utility of using stenosis severity to guide management of coronary artery disease.37
A new management strategy has been proposed based on data suggesting that lipid-lowering favorably affects long-term outcome through plaque stabilization.37 The following sections will address how this might be carried out.