Author + information
- Jawahar (Jay) L. Mehta, MD, PhD⁎ ()
- ↵⁎University of Arkansas for Medical Sciences, Division of Cardiovascular Medicine, 4301 West Markham Street, Mail Slot 532, Little Rock, Arkansas 72205-7199
I read with great interest the review by Marzilli et al. (1) in a recent issue of the Journal. The authors make a compelling case that coronary artery disease (CAD) does not equal ischemic heart disease (IHD), or vice versa. They also show that angina symptoms do not always improve after coronary revascularization, whether surgical- or catheter-based. Certainly every seasoned cardiologist has seen patients who continue to have IHD symptoms despite open “native artery” or “bypass graft.” However, many asymptomatic patients have received percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the name of obstructive CAD. Then, there are others who are asymptomatic and have normal exercise tests despite bypass graft occlusion. These observations support the essay by Marzilli et al. (1).
Unfortunately, our profession has become catheter laboratory centric since the day we could see pictures of the live coronary artery. The advent of PCI has led to a new medical-industrial enterprise in which administrators, hospitals, and physicians are enthusiastic partners. So often one reads about greedy coronary interventionalists who have placed stents in arteries with minimal lesions or no lesions at all (2,3). These events have only served to lessen the public's trust in physicians in general, and cardiologists in particular. I feel a coronary intervention, such as a PCI, should be performed only in patients with acute myocardial infarction, and CABG should be performed in patients with 2- or 3-vessel disease with compromised left ventricular function.
We must realize that when we perform PCI or bypass surgery, we create a new form of coronary lesion that is prone to rapid atherogenesis, and give another disease to the patient, that is, coagulopathy, which is related to multiple antiplatelet and anticoagulant drugs. Being true to ourselves and performing a procedure when it is needed is the correct, moral, and ethical approach. This approach will go a long way in controlling ever-rising healthcare costs, and restore the public's trust in their caregivers. The Institute of Medicine has estimated that our country wastes $750 billion a year with inefficient utilization of resources, poor cost control, and excessive and unnecessary procedures (4). I urge all readers of the Journal to read this report.
- American College of Cardiology Foundation
- Marzilli M.,
- Bairey Merz C.N.,
- Boden W.E.,
- et al.
- Abelson R.,
- Creswell J.
- Harris G.
- Alsono-Zaldivar R.