Correspondence
Clinical Problem-Solving: Invasive Interventions
N Engl J Med 1995; 332:125-127January 12, 1995
- Article
To the Editor:
With respect to the Clinical Problem-Solving article describing a young man requiring coronary angioplasty (Sept. 1 issue),1 we wish to take issue with the discussant's statement that “it is difficult to find much fault with either the diagnostic or the therapeutic approach.” Despite a risk-stratification evaluation (involving normal results on a maximal stress test and a normal perfusion scan) that indicated his very low risk after an uncomplicated myocardial infarction, the patient underwent “obligatory” angioplasty for stenosis of the proximal left anterior descending coronary artery.
The physicians made only one objective measurement of the post-stenotic coronary blood flow (perfusion scintigraphy), and the result was, in fact, normal.2 It is likely, on the basis of previous correlative studies,3 that this lesion would not have been flow-limiting on direct measurement, further indicating that this patient would not necessarily benefit from mechanical intervention.4
It is curious that the patient returned with the same chest pain one week after a second procedure with 30 percent narrowing of the left anterior descending coronary artery and a potential thrombus (most likely at the hazy site of the previous angioplasty), an event that also points out the difficulty in using symptoms alone to decide on intervention.
This approach of treating angiograms rather than patients requires reexamination. As Topol et al. indicate,5 patients similar to the one described are subjected to the physician's “oculo-stenotic reflex,” undergoing angioplasty with no objective evidence of myocardial ischemia. As in this case, physicians frequently ignore important clinical information and proceed with angioplasty on the basis of the “ominous” appearance of a lesion on angiography.5
There is no doubt that some angiographically important lesions that are treated medically in the acute ischemic phase may require angioplasty or surgery, especially in young patients with extensive myocardium at risk. However, in patients in stable condition during the convalescent phase, and more so in those who have normal maximal stress tests, the rationale for angioplasty is not supported by data, but rather by bias without consideration of the fact that further interventions may lead to a cycle of restenosis and bypass surgery sooner than the natural history of the disease would dictate.
With respect to costs, in this case cardiac catheterization was performed despite negative noninvasive tests. The physicians made their decision on the basis of angiographic findings alone, ignoring the results of the tests they had ordered. The comprehensive discussion of the case fails only in not faulting this approach. It would be interesting to see whether clinical management decisions would be affected if reimbursement for such interventions were linked to objective data.
5 ReferencesMorton J. Kern, M.D.
Richard G. Bach, M.D.
St. Louis University Health Sciences Center, St. Louis, MO 63110-02501
Pauker SG ,Kopelman RI . Invasive interventions. N Engl J Med 1994;331:601-605
Full Text | Web of Science | Medline2
Miller DD ,Donohue TJ ,Younis LT , et al. Correlation of pharmacological 99mTC-sestamibi myocardial perfusion imaging with poststenotic coronary flow reserve in patients with angiographically intermediate coronary artery stenosis. Circulation 1994;89:2150-2160
Web of Science | Medline3
Donohue TJ ,Kern MJ ,Aguirre FV , et al. Assessing the hemodynamic significance of coronary artery stenoses: analysis of translesional pressure-flow velocity relations in patients. J Am Coll Cardiol 1993;22:449-458
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Kern MJ, Donohue TJ, Aguirre FV, et al. Clinical outcome of deferring angioplasty in patients with normal translesional pressure and flow velocity measurements. J Am Coll Cardiol (in press).
5
Topol EJ ,Ellis SG ,Cosgrove DM , et al. Analysis of coronary angioplasty practice in the United States with an insurance-claims data base. Circulation 1993;87:1489-1497
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To the Editor:
The Clinical Problem-Solving case presented by Pauker and Kopelman contained an interesting discussion about the care of a young patient with chest heaviness, particularly with respect to the point that “cardiologists are much maligned for their narrow focus on technology and excessive use of medical resources.” We would like to expand that discussion by including the results of a recent randomized trial by Goy et al.1 This study extends the conclusions of previous studies comparing percutaneous transluminal coronary angioplasty and coronary-artery bypass grafting (with use of the left internal thoracic artery) to the clinical setting of symptomatic, isolated involvement of the proximal left anterior descending coronary artery in patients with normal left ventricular function. The trial demonstrated that, despite a longer hospitalization and higher costs in the short term in the group that underwent coronary-artery bypass grafting, the group had fewer interventions and symptoms and a lower intake of antianginal drugs than the angioplasty group after a median follow-up of 2.5 years.
1 ReferencesMaria Luiza de Alencastro Kallfelz
Ramiro Caldas Degrazia
Rua Coronel Marcos, 800, 91760-000 Pôrto Alegre, Brazil1
Goy JJ ,Eeckhout E ,Burnand B , et al. Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis. Lancet 1994;343:1449-1453
CrossRef | Web of Science | Medline
To the Editor:
Pauker and Kopelman mentioned that “other procedures, such as atherectomy, lessen the rate of restenosis only slightly.” In fact, even this slight reduction is not statistically significant and results in no additional clinical benefit.
In a trial comparing atherectomy with balloon angioplasty in native coronary arteries, the rate of restenosis was only marginally and nonsignificantly lower with atherectomy (50 percent in the atherectomy group vs. 57 percent in the angiography group; P = 0.06), and this difference was not associated with improvement in clinical outcome.1 In a trial comparing atherectomy with balloon angioplasty in the proximal segment of the left anterior descending coronary artery, the rate of restenosis was 46 percent in the atherectomy group and 43 percent in the angioplasty group (P = 0.71).2 The only new procedure known to reduce the rate of restenosis significantly is elective coronary stenting, as demonstrated in two recent trials comparing stenting with balloon angioplasty in native coronary arteries.3,4 The rate of restenosis in one of the studies3 was 22 percent in the stent group and 32 percent in the angioplasty group (P = 0.02). The other study4 reported a similar finding (rate of restenosis, 31.6 percent in the stent group and 42.1 percent in the angioplasty group; P = 0.046).
It is surprising that coronary atherectomy is currently used in more than 15 percent of all coronary interventions in the United States, in spite of its higher cost1 and lack of additional clinical benefit.
4 ReferencesIyad Rashdan, M.D.
Presbyterian Medical Center, Philadelphia, PA 191311
Topol EJ ,Leya F ,Pinkerton CA , et al. A comparison of directional atherectomy with coronary angioplasty in patients with coronary artery disease. N Engl J Med 1993;329:221-227
Full Text | Web of Science | Medline2
Adelman AG ,Cohen EA ,Kimball BP , et al. A comparison of directional atherectomy with balloon angioplasty for lesions of the left anterior descending coronary artery. N Engl J Med 1993;329:228-233
Full Text | Web of Science | Medline3
Serruys PW ,de Jaegere P ,Kiemeneij F , et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994;331:489-495
Full Text | Web of Science | Medline4
Fischman DL ,Leon MB ,Baim DS , et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med 1994;331:496-501
Full Text | Web of Science | Medline
To the Editor:
Pauker and Kopelman rightly ask whether it shouldn't be routine to counsel relatives of a young patient with a myocardial infarction about diet, smoking, and drug abuse. Pediatricians are taught that the finding of a history of cholesterol elevation or heart attack at a young age in a parent or grandparent is reason to check the cholesterol level of any child over the age of two years.1 I have never yet met a set of parents who reported to me that Grandpa had a heart attack or Dad's cholesterol was elevated and that an internist, family practitioner, or cardiologist had advised that their child be tested.
The practitioner who resuscitates a patient who is having a massive heart attack is considered a hero, but the true heroes are the practitioners whose care prevents the heart attack in the first place. As health care reform becomes a reality, this point must be respectfully considered.
1 ReferencesDeborah Tolchin, M.D.
Albert Einstein College of Medicine, Bronx, NY 104691
American Academy of Pediatrics Committee on Nutrition
Web of Science | Medline
To the Editor:
In their Commentary, Pauker and Kopelman state: “we know from data obtained 25 years ago that the management of acute myocardial infarction in a coronary care unit saves lives.” We disagree. Randomized, controlled trials published in the 1970s1-3 failed to demonstrate that admission to a hospital improved survival among patients with myocardial infarction.
Perhaps now that thrombolysis and interventional procedures are widely used in patients with acute myocardial infarction, the role of the hospital in improving the survival of these patients could be substantiated. We are not aware of any study published in the past 25 years that demonstrates increased survival in patients with acute myocardial infarction who were cared for in coronary care units, and certainly no such study is cited in the textbooks4,5 referred to by Pauker and Kopelman to support their contention.
5 ReferencesBasilio J. Anía, M.D.
Miguel A. Cárdenes, M.D.
Hospital Neustra Señora del Pino, 35005 Las Palmas, Canary Islands, Spain1
Mather HG ,Pearson NG ,Read KLQ , et al. Acute myocardial infarction: home and hospital treatment. BMJ 1971;3:334-338
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Mather HG ,Morgan DC ,Pearson NG , et al. Myocardial infarction: a comparison between home and hospital care for patients. BMJ 1976;1:925-929
CrossRef | Web of Science | Medline3
Hill JD ,Hampton JR ,Mitchell JR . A randomised controlled trial of home-versus-hospital management for patients with suspected myocardial infarction. Lancet 1978;1:837-841
CrossRef | Web of Science | Medline4
Pasternak RC, Braunwald E. Acute myocardial infarction. In: Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL, eds. Harrison's principles of internal medicine. 13th ed. Vol. 1. New York: McGraw-Hill, 1994:1066-77.
5
Sobel BE. Acute myocardial infarction. In: Wyngaarden JB, Smith LH, Bennett JC, eds. Cecil textbook of medicine. 19th ed. Philadelphia: W.B. Saunders, 1992:304-18.
Author/Editor Response
The authors reply:
To the Editor: The diversity of opinions about this case underscores the controversy surrounding the care of patients with symptomatic stenoses of the left anterior descending coronary artery. Drs. Kern and Bach argue that the normal results of noninvasive studies imply that this young man's stenosis of 90 to 95 percent would not be “flow-limiting,” but most series suggest a worrisome prognosis for patients with stenosis of the proximal left anterior descending coronary artery, electrocardiographic changes, and unstable symptoms.
Ms. Kallfelz and Mr. Degrazia argue for bypass surgery for symptomatic, isolated stenosis of the left anterior descending coronary artery; the preliminary results of the European trial they refer to contribute to a growing tide of short- and intermediate-term studies suggesting that aggressive revascularization leads to fewer symptoms and less contact with the health care system, although effects on survival and cost are less obvious. A meta-analysis shows a marginally significant 10-year survival benefit for bypass surgery as compared with conservative therapy in patients with single-vessel disease of the left anterior descending coronary artery.1
We agree with both Dr. Rashdan and our discussant that, as compared with angioplasty, atherectomy does not alter the likelihood of restenosis or survival. Dr. Rashdan suggests that it might be appropriate to use a stent, but the long-term results of such therapy are unknown. Nonetheless, some investigators have suggested that primary stenting for single-vessel disease may be economically reasonable, especially if the likelihood of restenosis is high, as in the case of disease of the left anterior descending coronary artery.2
Dr. Tolchin reminds us, appropriately, that coronary disease is best managed by prevention and that the identification of an affected patient often serves to identify a family in which the children are at risk.
Drs. Anía and Cárdenes refer to two older British studies that have been criticized for including only selected low-risk patients and for having inadequate power.3 Since Killip's classic report of improved survival among moderate- and high-risk patients who were cared for in a coronary care unit,4 clinicians have tried to identify low-risk patients who would not benefit from such care. The modern coronary care unit remains sufficiently effective in treating early, potentially lethal cardiac arrhythmias to serve as the standard of care for the treatment of most patients with acute infarction.
4 ReferencesStephen G. Pauker, M.D.
Richard I. Kopelman, M.D.
New England Medical Center, Boston, MA 021111
Yusuf S ,Zucker D ,Peduzzi P , et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994;344:563-570
CrossRef | Web of Science | Medline2
Cohen DJ ,Breall JA ,Ho KK , et al. Evaluating the potential cost-effectiveness of stenting as a treatment for symptomatic single-vessel coronary disease: use of a decision-analytic model. Circulation 1994;89:1859-1874
Web of Science | Medline3
Lee TH ,Goldman L . The coronary care unit turns 25: historical trends and future directions. Ann Intern Med 1988;108:887-894
Web of Science | Medline4
Killip T III ,Kimball JT . Treatment of myocardial infarction in a coronary care unit: a two year experience with 250 patients. Am J Cardiol 1967;20:457-464
CrossRef | Web of Science | Medline
