Revascularization wars
There is a great article by Professor David Taggart , also mentioned by Professor Tom Treasure, about the current interpretation of clinical trials comparing PCI (mainly stenting) against CABG. One of the main premises is that cardiologists are not providing the standard of care of revascularization, stemming from (or is justified by) revascularization trials that include a significant proportion of patients with coronary disease distribution that are known not to derive survival benefit with CABG.
Whilst I would love nothing more than to support any cause that would lead to more work for the specialty, I think there is more to the debate.
Wouldn’t it be really unethical to randomize patients with coronary disease anatomy that are already known to derive a survival benefit from CABG to receive PCI? Also, there is no onus to prove that CABG is superior. As far as I can see, the PCI trials ask a different question: `in patients who are amenable to both form of treatment, is there any difference in the outcome between PCI and CABG?’. The trials mainly have the same message, which is lower re-intervention with CABG and no difference in survival. An interesting exception is the SOS trial, where survival was statistically significantly improved with CABG, but the result was glossed over by the reporting authors ("The apparent reduction in mortality with CABG requires further investigation").
We will never stand a fair chance in any revascularization war.
The foremost reason is because cardiologists remain the gatekeepers for referrals for revascularization, stemming from investigation (angiography) of patients with chest pain / angina which comes from chest pain clinics. Maybe we should start holding chest pain clinics or else we need to resign to the current referral practice.
The golden opportunity missed by a generation of cardiac surgeons to take over diagnostic angiography from radiologists, was a move that subsequently led cardiologists to percutaneous coronary intervention. I am sure that surgeons would have superior dexterity and manual skills, if only we had a little more interest and foresight.
Almost invariably, the principal investigators of clinical trials of comparing the two modes of revascularization are cardiologists. Therefore much of the reporting (like the SOS trial) and interpretation of the clinical trial results are performed by cardiologists. Perhaps we need to take the lead in future trials.
The final nail in the coffin must be patient choice. Even if all the facts are presented to the patient fairly, how many would prefer open heart surgery to a less invasive temporizing procedure? Be honest!
I don’t think I’m writing anything that is not already known by all of us. With personal, departmental, financial interests that accompany the revascularization workload and cardiologists sitting at the helm of research, diagnostic investigation and gate keeping, all that is left for people like me to do is to write lamenting articles like this!