This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Pepine, C. J. Articles by Deedwania, P. C. Search for Related Content PubMed PubMed Citation Articles by Pepine, C. J. Articles by Deedwania, P. C.

(Circulation. 1998;98:1985-1986.)
© 1998 American Heart Association, Inc.

Editorial

How Do We Best Treat Patients With Ischemic Heart Disease?

Carl J. Pepine, MD; ; Prakash C. Deedwania, MD

From the University of Florida, College of Medicine, Division of Cardiovascular Medicine, Gainesville (C.J.P.) and the University of San Francisco School of Medicine and VA Medical Center, Fresno, Calif (P.C.D.)

Correspondence to Carl J. Pepine, MD, Chief, Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 Archer Rd, Gainesville, FL 32610-0277.

Key Words: Editorials • ischemia • trials

Despite investigations over several decades, it is still difficult to define an optimal treatment strategy for patients with ischemic heart disease. Some of the many reasons for this dilemma include delayed and highly variable symptomatic presentation, lack of a clear relationship between symptom severity and outcome, a changing population (aging and more women), changing therapies, and a relatively low overall event rate for patients in the chronic stable phase. The problem is placed into focus, however, when one considers that as the "baby boomers" age, we will see a marked increase in the prevalence of ischemic heart disease without a clear understanding of how aggressive we should be with our medical approach and whether expensive revascularization procedures offer clear benefit over the best medical approach.

The prevailing notion from past trials¹ is that subgroups of patients with ischemic heart disease, principally those with anatomic findings suggesting the potential for severe ischemia (left main stenosis or severe multivessel disease with impaired left ventricular function²), may do better with surgical revascularization than medical therapy. But these are only a small and select fraction of ischemic heart disease cases, and these results are dated by older technologies.

Yet, in patients who were asymptomatic or mildly symptomatic after infarction, 3 small randomized trials of CABG surgery versus medical therapy have shown no distinct benefit in favor of surgery. Norris et al³ addressed this issue in 100 consecutive patients believed to be at high risk because they had second or third infarctions. The majority . . . [Full Text of this Article]