Comparing Two Treatments for a Common Form of Heart Disase

The results of a clinical trial published in today's (March 5, 2009) issue of the New England Journal of Medicine have demonstrated that the traditional surgical, or "open-chest," treatment for the most common form of heart disease in adults is sometimes superior to the less invasive, and generally less expensive, form of treatment known as "stenting."

The study, known as the "Synergy between PCI with Taxus^® and Cardiac Surgery (SYNTAX)"trial, was supported by funding from the National Institutes of Health. Its purpose was to determine if there were any significant differences between the 1-year outcomes of two commonly-used treatments for coronary artery disease (or, as it is usually abbreviated, CAD).

In CAD, the arteries that supply blood to the heart muscle itself become narrowed by the presence of abnormal deposits of cholesterol that are known as plaques. If too little blood flow reaches the heart muscle a special type of chest pain known as angina pectoris occurs and, if not treated aggressively, a heart attack may occur. CAD can sometimes be treated with medication alone, but this is often gives unsatisfactory results.

Since the late 1960s the preferred treatment of CAD has been the surgical placement of veins taken from the patient's legs to bypass the obstructions to blood flow. This operation, Coronary Artery Bypass Grafting, usually abbreviated as CABG (and pronounced "cabbage") is considered to be the "gold standard" against which the success of other treatments are measured. Beginning the 1980s however, the use of tiny stents that were inserted into the diseased arteries via a thin catheter (Percutaneous Coronary Intervention, or "PCI," also known as "angioplasty") became more common as an alternative to CABG.

The SYNTAX study addressed only the issue of whether there were any significant differences in the success rates of the two procedures during the first year of treatment.

SYNTAX followed the case histories of some 1500 patients that had received one of the two procedures. After one year, SYNTAX found that those undergoing PCI had a higher incidence (17.8%, vs. 12.4% for CABG) of subsequent heart-related complications (defined as a heart attack or the need for a second heart operation) but that those who had CABG were much more likely to have suffered a stroke (13.5% vs.5.9%) than those in the PCI group. Although not addressed in SYNTAX, the reason for the latter difference is most likely related to the greater risk of stroke in the immediate post-operative period in those having CABG.

So, you may ask, what's the big deal about SYNTAX?

You may rest assured that clinical studies such as the SYNTAX trial will assume a far greater prominence under the Obama Administration's as yet undisclosed (but projected to cost some $80 billion per year, assuming that inflation simply disappears) scheme to nationalize the American health care industry. My point is simply this:

Do you want medical decisions involving you, or some member of your family, made on the basis of what is the most likely to produce the greatest potential benefit or have such decisions made for you by some government "bean-counter" because one treatment is cheaper than another?

I won't insult your intelligence by asking for an answer.

For those readers wishing more information, please see the following publications.

PW Serruys et al. Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease. NEJM 360:10, March 5, 2009, 961-972.

RA Lange and LD Hillis. Coronary Revascularization in Context. NEJM 360:10, March 5, 2009, 1024-1026.