David P. Taggart
As a member of the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) which published the ESC/EACTS Guidelines on Myocardial Revascularization at the ESC meeting in Stockholm and the EACTS meeting in Geneva late in 2010， Professor David Taggart is well qualified to outline the evidence and rationale applied in arriving at the final document. Professor Taggart will present an outline of the Guidelines and how it may be applied in the Chinese environment during an "All you need to know" Joint Scientific Session on left main and multivessel disease， PCR & ESC Working Group on Cardiovascular Surgery， on Thursday afternoon.
While there is general consensus from randomized trials， not least the landmark SYNTAX Trial， and large propensity matched registries that CABG still offers a survival benefit and a marked reduction in the need for repeat revascularization in the most severe and complex coronary artery disease （figure）， CABG and stents appear to offer similar survival outcome， at least over the short to medium term， in patients with lower SYNTAX score severity coronary artery disease. Using the Arterial Revascularization Trial (ART) as an indicator， Professor Taggart concludes that “the results of contemporary CABG are excellent!”， but could be even better. More use of arterial grafts， more off pump CABG in higher risk patients and confirmation of graft patency in the operating room are all avenues for improvement. Alarmingly， there is strong evidence that most PCI patients misunderstood the procedure and that ‘ad hoc’ stenting (i.e.， the decision to proceed with stenting immediately after diagnostic angiography) denies real patient choice and genuine informed consent.
With these factors in mind， the guidelines are comprehensive and recognize the need for a cohesiveness applicable to the management of the entire spectrum of coronary artery disease. While less severe disease can be adequately treated by lifestyle changes and optimal medical therapy， more severe disease may additionally require intervention by stenting or surgery.
New to the guidelines is an individual section on the process of decision making and patient information which calls for a more formal multidisciplinary approach when recommending intervention by stents or surgery， outside of the context of STEMI where primary stenting is the treatment of choice and should be performed without delay. In the same way that these collaborative guidelines drew on the expertise and non-commercial input of a writing committee of 25 members including nine non-interventional cardiologists， eight interventional cardiologists and eight cardiac surgeons， it is now advocated that most recommendations for intervention in clinical practice be made by a ‘Heart Team’ consisting of a core of a non-interventional cardiologist， an interventional cardiologist and a cardiac surgeon and additional expertise where necessary. Although yet untested in randomized controlled trials， the multi-disciplinary team approach would appear to not only serve the best interests of patients with coronary artery disease (as it does for cancer patients)， but it also enhances and safeguards the interests of doctors.
Guidelines are not prescriptive and the ultimate judgement regarding the care of an individual patient must be made by his/her physician(s). Thus， Guidelines are only useful if they can be implemented locally and recommendations also need to be interpreted in the social， cultural and economic context of the patient and their family.
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