Carrel, Thierry

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European Journal of Cardio-Thoracic Surgery 47 (2015) 860–861 EDITORIAL COMMENTdoi:10.1093/ejcts/ezu322 Advance Access publication 21 August 2014Cite this article as: Carrel T. Lack of evidence-based practice leads to major geographical variations in elective coronary revascularization by stents orsurgery in England. Eur J Cardiothorac Surg 2015;47:860–1.Lack of evidence-based practice leads to major geographicalvariations in elective coronary revascularization by stents orsurgery in EnglandThierry Carrel*Clinic for Cardiovascular Surgery, University Hospital, Berne, Switzerland* Corresponding author. Clinic for Cardiovascular Surgery, University Hospital, 3010 Berne, Switzerland. Tel: +41-31-6322375; fax: +41-31-6324443;e-mail:thierry.carrel@insel.ch (T. Carrel).Keywords: Coronary artery disease • Coronary artery bypass grafting • Percutaneous coronary intervention • Geographical differences •Guidelines • Impact on practiceSince their introduction, coronary artery bypass grafting (CABG)and percutaneous coronary intervention (PCI) have become thestandards of care for the large majority of patients with coronaryartery disease (CAD) and, by the way, two of the most performedprocedures in medicine, worldwide. Both therapies are ubiqui-tously available in the western world but, interestingly, there arelarge differences in the provision of PCI and CABG: ﬁrst betweendifferent countries and, as demonstrated by Baig et al., also withinthe same country with a maximal degree of variation of the ratioPCI/CABG of more than 13-fold. The authors have to be congratu-lated for bringing these important pieces of informations to thereadership of EJCTS and thereby for stimulating thought on howto interpret these numbers?In the last 20 years, numerous randomized trials comparingPCI to CABG have shown comparable outcomes for selectedpatient populations [1, 2] and provided more evidence for wideruse of PCI despite the fact that several developments (off-pumpsurgery, minimized extracorporeal technology, improved myo-cardial protection, endoscopic vein harvesting) have made CABGless invasive and highly competitive to PCI. Unfortunately, andbecause CABG is sometimes described by cardiologists as a pro-cedure where ‘the chest is cracked open’, patients often preferPCI to CABG because they believe a stitch in the groin is alwaysbetter than a scar on the chest. In addition, a shorter stay in hos-pital and the hope for a shorter rehabilitation are attractiveprospects.The paper by the group of David Taggart present someexpected but also some unexpected items of information con-cerning the provision of PCI and CABG in the UK [3]. It is veryinteresting for several aspects: it shows that the provision of PCIand CABG (expressed at least partially by the ratio of PCI to CABG)may be extremely different, even in the same country. In addition,the authors have shown that these differences were not patientrelated and cannot be explained by the volume of interventionsperformed. The large differences in the treatment of CAD in theUK call for additional hypotheses:(i) the geographical location of the cardiology and cardiacsurgery units;(ii) the organization of the cardiology unit (run alone or with acardiac surgery unit);(iii) the presence or not of a heart team on the site;(iv) and ﬁnally from the knowledge and education of generalpractitioners and patients.For judicious decision-making in every single patient, it is essen-tial to consider the risk/beneﬁt ratios of both procedures; thismeans careful evaluation of procedural invasiveness and theassociated short-term complications against the probability of anadverse long-term event (death, myocardial infarction, repeatrevascularization and absence of improvement in quality of life).The lecture of this paper leads to some comments: some aredirectly related to the observations described in this paper, whileothers are general statements on how patients with signiﬁcantCAD are dealt with today in a majority of institutions:(i) First of all, both the European Society of Cardiology and theEuropean Association for Cardio-Thoracic Surgery havepublished Guidelines for the treatment of CAD [4]. While theindications have been described in detail for every type ofcoronary vessel involvement, it is surprising to assert that asubstantial proportion of patients are treated by PCI outsideof evidence-based indications [5].(ii) In several situations, it appears that the patients decide—onthe basis of a biased piece of information through cardiolo-gists—which type of treatment should be performed. Dothe patients have enough knowledge for this? Certainly not.Let us just imagine a similar decision-making situation inoncology: the patient would choose the option with theless durable results, just because it is less invasive (or itcauses less side-effects) but is followed by a higher rate ofrecurrences!(iii) It is a clear fact that the information given to the patients inthe cath lab disproportionally emphasizes short-term resultsS.S. Baig et al. / European Journal of Cardio-Thoracic Surgery860even though CABG has been shown to be superior to PCIwith respect to long-term survival and angina relief, at leastin the presence of left main stenosis and three-vesseldisease.(iv) There have been extended discussions about the necessityand the value of ‘heart teams’ in the recent literature, notonly following the results of the SYNTAX study but also toimplement robust TAVI programmes. Unfortunately, theheart team approach is usually considered as a ‘nice to have’option and not as an effective discussion tool to exchangescientiﬁc arguments between cardiologists and cardiac sur-geons. As a result of this, for instance, the SYNTAX score,which was warmly recommended in the publications, is notused routinely in a majority of institutions.(v) The value of ‘ad hoc’ PCI should be questioned. Although itis desirable to improve the efﬁciency within the organization(saving money and reducing delay until deﬁnitive treat-ment), it is not the best solution for all patients. Ad hoc PCIdoes not allow in-depth discussion with colleagues andpatients. In addition, this approach does not allow an alter-native treatment (CABG) to be presented to the patient thecardiologist informs the patient about CABG surgery (!!!).This is medically not justiﬁable and ethically questionable.(vi) In the last decade, there has been an explosion of cardi-ology units that are able to offer PCI without the neednor the possibility to properly discuss the pros and consbut sometimes in those patients in whom CABG wouldlead to superior results. Moreover, when problems happenduring the short- or mid-term follow-up, the controlexaminations are usually performed by the same team thatprovided the initial PCI. This precludes a critical appraisaland control of the results obtained by PCI.(vii) Finally, a word of caution is needed: cardiologists are notalways responsible for this development. Hospital managersnowadays deal increasingly (when not exclusively) withﬁnancial incentives when the budgets of their units areconcerned. Therefore, health-care providers (in this casecardiologists) have only the possibility of increasing thenumber of PCIs (in the worst scenario with marginal oreven inappropriate indication) to fulﬁl the budget numbersand satisfy their managers. These incentives are not onlyperverse but also expensive for the overall healthcaresystem. A discussion in depth is urgently needed to ﬁx theseproblems.The SYNTAX trial has been a signiﬁcant work to establish theoptimal revascularization strategies for patients suffering fromCAD with left main stenosis disease and three-vessel disease.Signiﬁcant differences were found following CABG and PCIbetween patients with left main stenosis and three-vessel disease.Since this trial has provided strong evidence that CABG is superiorto PCI in reducing long-term adverse clinical end-points likedeath and myocardial infarction, one can hope that the resultsdescribed in the paper of Braig et al. belong to the past.REFERENCES[1] Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MMet al. Coronary artery bypass surgery compared with percutaneous coron-ary interventions for multivessel disease: a collaborative analysis of individ-ual patient data from ten randomised trials. Lancet 2009;373:1190–7.[2] Head SJ, Davierwala PM, Serruys PW, Redwood SR, Colombo A, Mack MJet al. Coronary artery bypass grafting versus percutaneous coronary inter-ventions for patients with three-vessel disease: ﬁnal ﬁve-year follow-up ofthe SYNTAX trial. Eur Heart J 2014;35:2821–30.[3] Baig SS, Altman DG, Taggart DP. Major geographical variations in electivecoronary revascularization by stents or surgery in England. Eur JCardiothorac Surg 2015;47:855–9.[4] Wijns W, Kolh P, Danchin N, Di Mario C, Falk V, Folliguet T et al. Guidelineson myocardial revascularization. Eur J Cardiothorac Surg 2010;(38 Suppl):S1–S52.[5] Yates MT, Soppa GK, Valencia O, Jones S, Firoozi S, Jahangiri M. Impact ofEuropean Society of Cardiology and European Association for Cardio-thor-acic Surgery Guidelines on Myocardial Revascularization on the activity ofpercutaneous coronary intervention and coronary artery bypass graftsurgery for stable coronary artery disease. J Thorac Cardiovasc Surg 2014;147:606–10.ADULTCARDIACS.S. Baig et al. / European Journal of Cardio-Thoracic Surgery 861

Lack of evidence-based practice leads to major geographical variations in elective coronary revascularization by stents or surgery in England

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Lack of evidence-based practice leads to major geographical variations in elective coronary revascularization by stents or surgery in England

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