ISCHAEMIC HEART DISEASE

The return of CABG over PCI? ▸

Clinical trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stents suggest no difference in most patients with significant disease in two or three vessels in the important outcomes of death and recurrent myocardial infarctions. Registry data provides information on larger cohorts of real life patients. New York’s cardiac registries identified 37 212 patients with multivessel disease who underwent CABG and 22 102 patients with multivessel disease who underwent PCI from 1 January 1997 to 31 December 2000. The rates of death and subsequent revascularisation within three years after the procedure in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the left anterior descending (LAD) coronary artery were assessed. Risk adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio (HR) for the long term risk of death after CABG relative to stent implantation was 0.64 (95% confidence interval (CI) 0.56 to 0.74) for patients with three vessel disease with involvement of the LAD coronary artery and 0.76 (95% CI 0.60 to 0.96) for patients with two vessel disease with involvement of the non-proximal LAD coronary artery. Since it is registry data, with patients assigned to groups by clinicians assessing relative benefits, perhaps the unadjusted analysis—which shows that surgery is only better in three vessel disease with proximal LAD disease—is more valid. This study raises questions about how cardiologists should advise patients.

Nicotine patches for free increase quit rates ▸

New York has an aggressive anti-smoking policy. After legislation and increased taxes, a six month study of providing free nicotine replacement therapy (NRT) patches suggests that quit rates are increased at a cost of about £300 per quit. From 34 090 eligible …