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It is probably fair to say that the relationship between cardiologists and cardiac surgeons is currently a little strained. True, there has always seemed to be something of an edge to this relationship, but the ongoing “turf wars” in coronary revascularisation have apparently increased the tension. The question is, does this tension serve to benefit patients with coronary disease, or would a better understanding of what “the other side” does allow us to make the right decisions and give the right advice to our patients?
The aim of this article, therefore, is to highlight some of the areas where uncertainty may arise, and hopefully provide cardiology trainees with some additional insights into the surgical management of patients with coronary artery disease. In depth treatment is clearly not possible here and further reading is suggested in the bibliography.
Key points 1: Evidence base for coronary artery surgery
CABG is the most intensively studied surgical procedure ever with over 20 years of follow-up data.
CABG is highly effective in relieving the symptoms of coronary heart disease.
CABG improves life expectancy in certain anatomical subsets, and this benefit is increased in the presence of impaired left ventricular function.
Despite an ageing surgical population with increasing comorbidity, CABG is a safe procedure with hospital mortality of 1–2%.
CABG has been demonstrated to be extremely cost effective in the long term.
THE EVIDENCE BASE FOR CORONARY ARTERY SURGERY
Coronary artery bypass graft surgery (CABG) is carried out either to relieve symptoms or improve prognosis. It has been compared against medical treatment in three large randomised trials: the Coronary Artery Surgery Study (CASS), the Veterans Administration Study, and the European Coronary Surgery Study. There have also been several smaller trials and several large registries. These studies took place during the 1970s and therefore have clear shortcomings when applied to current practice:
Patient selection largely excluded females, age >65 years, poor left ventricular …