Thursday, May 26, 2005

NEJM headline news-CABG better than stents (at least they were in the past)

The May 26 issue of the NEJM article "Long-term outcomes of coronary artery Bypass grafting versus Stent implantation" concludes in part ". For patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting".
So is the issue settled?.Of course not. This is a very large data base (37,212 patients), so robust conclusions should be drawn and clinical practice illuminated. Well maybe not.
The procedures took place between Jan 1, 1997 and Dec 31, 2000 and since then both stent procedures, surgical techniques and supportive medical therapy have changed. One highly publicized change is the introduction of the drug eluting stents which have markedly decreased stent related re-stenosis. Post stent patients now are ( or should be treated) routinely with multiple drugs which are likely in the aggregate to decrease disease progression. Statins, ACE inhibitors, ASA , Plavix, beta blockers are widely used under the rubic of risk factor reduction for post surgical patients as well as post stent patients.
If drug eluting stents had not been developed and if medication regimens had not been developed and if things were frozen in time as of Dec 21,2000 we would have the answer, namely, do CABG for patients with two or more vessel disease. But medicine is not static and- to the degree that is true-outcome research is always history. Sometimes, by the time we figure out if what we are doing is any good, we are doing something else.

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