Tuesday, May 15, 2012


Coronary artery disease is always in the limelight because of its prevalence and deadliness. Myocardial revascularisation either with CABG ( coronary artery bypass graft ) or PCI ( percutaneous coronary intervention ) is nowadays commonly performed. Of course, the common indications for myocardial revascularisation includes patients symptoms and also the presence of reversible stress induced myocardial ischemia. Meaning that we should not revascularise a patient if there are no symptoms, or now evidence of reversible myocardial ischemia on stress testing. In fact the COURAGE trial has shown us just that. In patients with chronic stable angina, without the presence of significant symptoms or the presence of reversible myocardial ischemia ( ie those picked up on routine CT angio screening ), revascularisation gives no benefit to the patients. The longterm outcome is just as good with intensive medical therapy.
Well, in  a way, a paper in the May 12 issue of the Archives of Internal Medicine further supports that. Dr Serge Harb and colleagues at the famous Cleveland Clinic Heart and Vascular Institute, studied 2,105 patients who had myocardial revascularisation a mean of 4.1 year earlier, routine stress echo done at annual follow-up, and follow them up for a further 5.7 years. These were all assymptomatic and well. It was just a routine stress echo as part of follow-up. 54% of these patients had PCI as the first procedure and 46% had CABG. These were all patients who had their first procedure between 2000 and 2010. Those who had failed the follow-up stress echo ( those with positive ischemia ), were re-revascularised. After 5.7 years of follow-up, the outcome in terms of mortality ( since they were asymptomatic, morbidity was the same ), were the same.
So if the mortality after 5 years is the same, why do the routine stress echo. That is the conclusion.
Routine stress echo after myocardial revascularisation, in an assymptomatic cohort confers no additional benefit. Routinely done, it is no better than a good history, including a history of their exercise capacity and a good medical examination. It only confers additional cost and maybe additional procedures with their attendant risk.
In my practice, I give the patient an option if they are assymptomatic. They could have their stress ECG ( I do not do stress echo as I find it less reliable in our setting ), yearly, if they wish or 2-3 yearly. I think that this is reasonable and this new findings make me more assured that we have been doing the right thing. If they can do all their life routines, and have an exercise capacity commensurate with their age, what is the problem? Is there a problem?
Basically, if they are well, good medical therapy is good for them. You cannot make them any better with invasive procedures.

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