BMJ  2005;330:E360 (11 June), doi:10.1136/bmj.330.7504.E360

Following are edited excerpts from Rapid Responses generated by this article, all of which can be read in their entirety at http://bmj.bmjjournals.com/cgi/eletters/330/7494/785.-Editor

BMJ USA: Letter

RAPID RESPONSES FROM BMJ.COM

There is only one valid randomized trial of coronary bypass surgery versus medical therapy, the US Coronary Artery Surgery Study (CASS). While this was conducted in the 1970s, and arterial conduits were less commonly used, the revolution in medical therapies for patients with ischemic heart disease over the last 30 years has been nothing short of staggering, and surely outweighs this difference in surgical technique substantially....

It seems plausible that the benefits of cardiac surgery, even for the most severe patterns of disease, are small. One in 50 will die within 30 days of their operation, there is still a very substantial risk of cerebral damage or "perturbation," and patients suffer a prolonged and painful recovery. If symptoms are severe enough to warrant revascularization, or patients are unable to go home because their symptoms are unstable, then PCI offers a quick, safer method of treatment, with a lower mortality, trivial risk of cerebral effects, similar outcomes, and an immediate recovery. Surely, most patients would opt for PCI under these circumstances.

It should also be made clear to patients that the life-saving effects of both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are really quite small, and this article has greatly underplayed that.

Manchester Heart Centre, Manchester MRI Oxford Road M13 9WL, UK

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Competing interests: I do not undertake CABG or PCI.

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RAPID RESPONSES FROM BMJ.COM

Sadly, the wider public health context is completely ignored. In fact, the population impact of cardiac surgery and angioplasty is surprisingly small. But why is that?

Coronary heart disease (CHD) typifies the iceberg of disease principle. Almost 3 million patients suffer from CHD in the UK.¹ Yet barely 60 000 patients undergo revascularization each year.

Meanwhile, between 1981 and 2000, CHD mortality rates in England and Wales fell by 62% in men and 45% in women aged 25-84. This represented 68 230 fewer deaths in 2000. Some 58% of this mortality fall was attributed to population risk factor reductions, principally smoking, also blood pressure and cholesterol.²

Treatments in individual patients accounted for some 42% of the mortality fall. However, the contribution from revascularization was only 4%,² much as in the USA.³ This was a disappointingly small contribution, particularly when considering the large financial and political resources being consumed.⁶

We suggest those resources might be better spent on prevention.^4,5

Department of Public Health, University of Liverpool Liverpool L69 3GB, UK

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Competing interests: None declared.

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RAPID RESPONSES FROM BMJ.COM

... Currently there is a wide range of available treatment options for coronary artery disease delivered by different specialists. Currently the "gatekeepers" are the cardiologists who perform diagnostic angiography. Unsurprisingly, many cardiac surgeons feel this introduces a bias into deciding on optimum treatment. The published results from comparative trials have not given a clear answer as to the relative superiority of surgery or angioplasty. Their interpretation has been dependent upon which specialist is looking at them. Also all the published trials are "historical" in that by the time they are published, new techniques have been introduced so that their results may no longer be relevant....

Kings College Hospital, Denmark Hill, London SE5 9RS, UK

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Competing interests: I regularly perform coronary artery surgery.

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Letter

RAPID RESPONSES FROM BMJ.COM

... Professor Taggart accepts that the 10 trials he has reviewed show a broadly similar mortality from CABG and PCI but chooses to concentrate on two trials that seem to favor surgery (although done predominantly in the bare metal stent era).

It is very unfortunate that this has been published just after the presentation at the American College of Cardiology of the newly available data from the ARTS II trial, which shows (albeit against historical controls) improved major adverse cardiac and cerebrovascular events at six months with drug-eluting stents compared with both the CABG and bare metal stent groups despite more extensive disease and treatment.

These data are presumably not available when the article was accepted: If they had been included, the conclusions of Professor Taggart's article would certainly have had to be markedly different, particularly his points about informed choice for patients and "best practice"....

Sussex BN11 2DH, UK

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Competing interests: I perform PCI, refer for CABG, and have received educational sponsorship from pharmaceutical and device companies.

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