Friday, July 11, 2008


Ever since coronary stenting became widespread, the rates of CABG worldwide, in USA and in Malaysia, have plummeted. I was at dinner with a close friend whose brother is a cardiac surgeon up north, and he was saying that brother was finding practice tough. Poor case load. I can understand. I told him to be patient. Looks like by-pass surgeons must re-invent themselves. Obviously given a choice, a patient would rather have a less invasive procedure, with a lesser risk, than a rather invasive CABG, off pump or not. Well, the cardiac surgeons are not keeping still. The July 7th online edition of Circulation, carries a 6 years followup of the original SoS ( Surgery or Stent ) trial of about 1000 patients who were randomised to either CABG or PCI with coronary stenting ( at that time-2001, it was bare metal stents ). At 6 years, just as it was at 5 years, CABG patients had a better survival ( lesser mortality ). To be fair, the mortality rates in both were low ( 6.8% Vs 10.9% ) at 6 years. Of course, this trial was not blinded. It was randomised, and the operators had some choice in case selection. I suppose the biggest problem with doing these kind of clinical trial is that the moment the trial is completed, it is somewhat outdated. Now, the cardiologist will argue that we have the Drug-Eluting Stents which are better, although DES has not been shown, consistently to improve survival, when compared with bare metal stents. What to do? No clinical trial is perfect. But I think the biggest problem with falling case loads with cardiac surgeons, is the fact that, it is the cardiologist who first sees the patient ( he is in-charge ), who clerks and workup the patient, including doing the angiogram, and on completing the angiogram, he decides on angioplasty or bypass surgery. Therein lies the biaseness., and conflict of interest. There is another PCI Vs CABG trial ( called the SYNTAX trial ) whose results are about to be released at the coming ESC meeting in September. I wonder what the results will show. But I doubt if another 10 trials supporting CABG will change the current practice patterns, because it is inherently bias for the cardiologist. Maybe insurance re-imbursement will. For the moment, I think, the interventional cardiologist will happily continue ballooning, always claiming that patient prefer angioplasty, until it can no longer be done ( usually for financial reasons ), and that refers him to the cardiac surgeon, who obviously sees the patient but cannot operate, because by then, the patient has run out of money. For your information, currently there is a large interventional meeting, costing millions of ringgit, going on in KL, propounding the merits of angioplasty, attended by GPs and technologist, and some interventionist. Now you know why angioplasty devices are so expensive. Well we must all have our hobby horses.

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