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Aziz O, Rao C, Panesar SS, et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. Br Med J 2007; 334:617-620. Meta-analysis of 12 studies (1952 patients) of minimally invasive left internal thoracic artery bypass for isolated lesions of the left anterior descending artery showed a higher rate of recurrent angina (odds ratio 2.6), incidence of major adverse coronary and cerebral events (OR 2.86), and need for repeat revascularisation (OR 4.6) with PCI but no significant difference in myocardial infarction, stroke, or mortality at median follow-up of 4 years.
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Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery
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Cost-effectiveness analysis showing that minimally invasive left internal thoracic artery bypass for isolated lesions of the left anterior descending artery may be a more cost-effective medium and long-term alternative to PCI
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Rao C, Aziz O, Panesar SS, et al. Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. Br Med J 2007; 334:621-623. Cost-effectiveness analysis showing that minimally invasive left internal thoracic artery bypass for isolated lesions of the left anterior descending artery may be a more cost-effective medium and long-term alternative to PCI.
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Ferguson Lecture. Coronary artery bypass grafting is still the best treatment for multivessel and left main disease, but patients need to know
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Taggart DP, Thomas B. Ferguson Lecture. Coronary artery bypass grafting is still the best treatment for multivessel and left main disease, but patients need to know. Ann Thorac Surg 2006; 82:1966-1975. Extensive review of the PCI and CABG literature in multivessel and left main-stem CAD illustrating in particular how randomized trials were biased against the prognostic benefit of CABG.
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BARI Investigators. The final 10-year follow-up results from the BARI randomized trial. J Am Coll Cardiol 2007; 49:1600-1606. Overall respective 10-year survival and reintervention rates in 1829 symptomatic patients with multivessel CAD was 71% and 77% for PCI and 74% and 20% for CABG. In the diabetic subgroup survival was better with CABG than PCI (58% vs. 46%).
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Pepper JR. Five-year results from the Stent or Surgery (SoS) trial. Proceedings of the World Congress of Cardiology; 2-5 September 2006; Barcelona. At 5 years in 908 patients there was superior overall survival for CABG vs. PCI (93.4% vs. 89.1%) and particularly in 142 diabetic patients (94.6% vs. 82.4%).
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Valgimigli M, Malagutti P, Rodriguez-Granillo GA, et al. Distal left main coronary disease is a major predictor of outcome in patients undergoing percutaneous intervention in the drug-eluting stent era: an integrated clinical and angiographic analysis based on the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) and Taxus-Stent Evaluated At Rotterdam Cardiology Hospital (T-SEARCH) registries. J Am Coll Cardiol 2006; 47:1530-1537. 130 patients with (94 with distal) LMS stenosis received DES. After a median of 20 months the cumulative incidence of major adverse cardiac events was 30% in patients with distal disease vs. 11% in those without (P = 0.007) mainly driven by the different rate of target vessel revascularization (13% vs. 3%; P = 0.02).
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Hannan EL, Racz M, Holmes DR, et al. Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era. Circulation 2006; 113:2406-2412. A total of 69% of all stent patients with multivessel CAD were incompletely revascularized, and 30% of all patients had total occlusions and/or at least two incompletely revascularized vessels. Incompletely revascularized patients were significantly more likely to die at any time (adjusted hazard ratio = 1.15) than completely revascularized patients. Those with total occlusions and at least two incompletely revascularized vessels were at the highest risk (HR = 1.36).
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Boden WE, O'Rourke RA, Teo KK, et al., COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356:1503-1516. Some 2287 patients who had objective evidence of myocardial ischemia and significant CAD were assigned to undergo PCI with optimal medical therapy (PCI group) or to optimal medical therapy alone (medical-therapy group). The 4.6-year cumulative primary-event rates were 19.0% in the PCI group and 18.5% in the medical-therapy group (P = 0.62). There were no significant differences between the PCI group and the medical-therapy group in the composite of death, myocardial infarction, stroke or hospitalization for acute coronary syndrome or myocardial infarction.
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Tung R, Kaul S, Diamond GA, Shah PK. Narrative review: drug-eluting stents for the management of restenosis: a critical appraisal of the evidence. Ann Intern Med 2006; 144:913-919. A critical reassessment of the published evidence questions the putative superiority of DES over BMS examining (a) overestimation of restenosis benefit, (b) underestimation of the risk for stent thrombosis, (c) overreliance on 'soft' rather than 'hard' outcomes (need for repeated revascularization vs. death or myocardial infarction), and (d) the attendant overestimation of cost-effectiveness.
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Luscher TF, Steffel J, Eberli FR, et al. Drug-eluting stent and coronary thrombosis: biological mechanisms and clinical implications. Circulation 2007; 115:1051-1058. The review focuses on the pathophysiological mechanisms and pathological findings of stent thrombosis in DES. Several factors are associated with an increased risk of stent thrombosis, including the procedure itself, patient and lesion characteristics, stent design and premature cessation of antiplatelet drugs, drugs released from DES impairing re-endothelialization resulting in a prothrombogenic environment, polymer-associated thrombosis and impairment of distal endothelial function.
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Grines CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol 2007; 49:734-739. This advisory stresses the importance of 12 months of dual antiplatelet therapy after placement of a DES and educating patients and healthcare providers about the hazards of premature discontinuation. It also recommends postponing elective surgery for 1 year, and, if surgery cannot be deferred, considering the continuation of aspirin during the perioperative period in high-risk patients with DES.
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Griffin SC, Barber JA, Manca A, et al. Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study. Br Med J 2007; 334:624-627. Prospective observational study comparing cost-effectiveness over 6-year follow-up of CABG, PCI or medical management within groups of patients rated as appropriate for revascularization. CABG seemed cost-effective but PCI did not and the clinical benefit of PCI may not be sufficient to justify its cost.
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