Posted in Uncategorized, tagged BARI 2D, courage, jasp, medical therapy vs pci for angina on March 31, 2012| 1 Comment »
COURAGE , BARI 2D , JASP
What is common in all ?
These are the studies which nailed the routine PCI in chronic stable angina . Please note these articles came in prestigious journals more than 5 years ago.
Nobody* seemed to listen or learn . Now the Archives of Internal Medicine has come out with another punch to PCI .
Hope we refuse to learn again . . . and keep the interventionist spirit high !
And for a change read this landmark paper from Forbes
Posted in Cardiology -Interventional -PCI, Cardiology -unresolved questions, Uncategorized, tagged BARI 2D, bari study, brazil mass 2, cass study, circulation journal mass 2 study brazil, courage, courage study, management of chronic stable angina, mass 1, MASS 2 10 year follow up, MASS 2 5 year follow up, mass 2 5 year folow up, mass 2 circulation, MASS 2 study, mass 2 trial, medical verses surgery verses pci, oat trail, stent or surgery study, what is MASS 2 study ?, zerbini foundation on October 28, 2010| 1 Comment »
MASS 2 study , the 10 year follow-up results are just out in circulation september 2010 .
It is a rare study , where “one to one vs one” was compared ie the effect of medical, CABG , and PCI in chronic CAD .This was done in a single centre in Brazil, between 1995 -2000 . It was followed up till 2010. Interestingly , such a study may not be possible in the future , as many of us have prematurely glorified the PCI and CABG over medical therapy . Recruiting patients for medical therapy alone is becoming a difficult job even in developing countries. Even if we recruit , huge cross over is likely to PCI, CABG for all fancy reasons.
So , in MASS 2 we have a rare treasure on hand . . . Let us give three cheers to those Brazilians who did this study , and shall carefully analyse and interpret the results.
Highlights ( According to my interpretation)
CABG tended to prevent future MI in this study . This could be most significant observation from this study ,( A revelation in fact ! ).It is against the popular belief created by CASS legacy.
What are the observed difference between MASS 2 – 5 year results , which was published in 2004 , and the 10 year follow-up , as on 2010 ?
At the end of 5 years in 2004 , the differences among the three groups were not obvious.The benefits of CABG mainly appeared after the 5th year and at 10 years it was significant.
Shortcoming of MASS 2
Intriguing thoughts
When we say medical therapy is being compared with PCI and surgery , we are actually comparing ,
Medical therapy alone
Medical therapy+ PCI
Medical therapy + CABG .
Every patient in all three groups receive statin , antiplatelet and beta blocking drugs and so on. Even though statistics would vouch for additional benefit , over and above medical therapy , in a given CABG individual , how much of the the accrued benefit is contributed by co- administering medical therapy .It is beyond reasoning even with all gimmicks of statistics.
To exactly quantify the individual benefits and efficiency of PCI , CABG and medical therapy two more study limbs are necessary .
Such a study is possible only in a virtual world ! . Decision making in favor of CABG , especially in chronic stable angina , will continue , to be difficult in the absence of refractory angina .This is due to the modest benefit of CABG , that is expected, at an additional risk , cost and expertise.
Please remember, a person can survive , only with medical therapy for > 10 years but no one can ever live with PCI or CABG for that period of time without adjunct drugs . Guess which modality is going to win the race against CAD in the long run ?
Final message
If any one asks for conclusion of MASS 2 study , don’t ever say “CABG is superior to medical therapy” . Please emphasize , “CABG + medical therapy could be , marginally superior to medical therapy alone in some of the patients with chronic stable angina. (Each word in the above statement is important !) .
So . . . MASS 2 : Is it a shot in the arm or shot in the head for CABG , we do not know !
http://circ.ahajournals.org/cgi/content/abstract/122/10/949
http://circ.ahajournals.org/cgi/content/full/122/10/949 .This study was done by Zerbini foundation Brazil
Posted in Uncategorized, tagged cabg, coronary collateral, coronary collateral circulation, courage, cto, LAD, lad 100%, lad stump, oat, pci, pda, rca to lad, toal lad on March 29, 2009| Leave a Comment »
Coronary collateral circulation is the most poorly understood, and often neglected concept among the cardiology community.There is a general perception , in obstructive CAD , coronary collaterals are an inferior modality of back up blood supply than artificial collateral (Also called CABG ) ! One of the reasons, it is been ridiculed by many mainstream cardiologists is because , it comes by nature , and also free of cost !
The often quoted statement* ,collateral blood flow can not sustain blood flow during exercise , is not based on solid scientific data. In the real world , there are thousands of patients actively pursuing life with chronic total occlusion and good collaterals.
It is surprising , there is no physiologically valid , controlled study available to compare CABG with natural collaterals
*When repeatedly told , a statement becomes a fact !
It can be assumed (Unscientifically ofcourse ! ) the remarkable success of medical therapy in COURAGE and the OAT * study can be attributable to the naturally occurring coronary collateral circulation.
* Summary of COURAGE & OAT : A block in the coronary artery need not be opened to prolong human survival !
You draw your own conclusions from the following case study
Dr.S.Venkatesan MD 