What do you want, surgery or medication? Looks like there is no clear choice. You may have to depend on your doctor's advice.

Research, conducted at the Heart Institute of the University of São Paulo Medical School in Brazil, appears in the Sept. 5, 2006, edition of the Journal of the American College of Cardiology.

For the study, scientists evaluated data collected during the Medicine, Angioplasty or Surgery Study II (MASS II) to determine how physician-recommended care affected patient outcomes one year after therapy. All patients were diagnosed with severe coronary artery disease affecting at least two blood vessels but still not causing a loss of heart function. Coronary artery disease occurs when a buildup of cholesterol in the arteries prevents oxygen-rich blood from nourishing the heart muscle.

"We still currently do not know which is the best therapeutic option for patients with multivessel chronic coronary artery disease and a normal ventricular function," said Whady Hueb, MD, PhD, a heart specialist at the University of São Paulo Heart Institute (InCor). "I think our study offers additional information and reassurance for both doctors and patients that, at the end of the decision-making process, what the doctor and patient agree is the best option in most cases really is the best option".

Dr. Hueb is senior author of the new study and principal investigator of MASS II, a randomized, controlled clinic trial looking for new ways to determine the most effective therapys for people with coronary artery disease.

For the study, 611 patients met with their individual heart specialists for evaluation. The physicians examined them and then, after conferring with a second heart specialist, recommended one of the three potential therapys: medication, noninvasive angioplasty using balloons and/or stents to open clogged arteries, or coronary artery bypass graft (CABG) surgery to reroute blood through new vessels grafted into place.

After the heart specialists made their recommendations, the patients were randomly assigned to receive a therapy. After one year, all records were evaluated to determine the percentages of patients who had died, experienced heart attacks or mandatory additional procedures to treat blocked arteries.

As per the research, patients assigned to receive their physician-recommended therapy showed a significantly lower occurence rate of problems. In contrast, patients assigned to a different course of therapy experienced a statistically significant increase in negative events (p = 0.02).

The most common - and only statistically significant - issue affecting this second group was the need for additional procedures to treat blocked arteries (p = 0.007.) No significant differences were found in either heart attack or death rates.

"Our data are a reminder that doctor judgment remains an important predictor of outcomes," said Alexandre C. Pereira, MD, a heart specialist at the University of São Paulo Heart Institute and one of the study's co-authors.

"We should always remember that the therapeutic decision option is the final result of a complicated equation that uses both objective and subjective variables, which will not necessarily be acquired by lab tests, imaging exams or objective questions in a clinical questionnaire," Dr. Pereira said. "In this scenario, doctor judgment - with all of the subjectivity that it may imply - still appears to be the best test or exam that a patient may have".

Ori Ben-Yehuda, MD, associate professor of medicine and director of coronary care at the University of California, San Diego, Medical Center, was not connected with the research but said it highlights why medicine will always be "an art not a science," and provides an intriguing new avenue for the future research of complicated medical conditions.

"The idea is quite ingenious and has never been done before," said Dr. Ben-Yehuda, a deputy editor of the Journal of the American College of Cardiology and author of an editorial that will accompany publication of the research. "The concept of recording a physician's judgment before conducting the randomization process to allocate patient therapy allows us to evaluate whether there are differences in outcomes based on that judgment.

"In other words, a doctor may notice a lot of little things that add up to one big thing," Dr. Ben-Yehuda said. "This big thing may go against the scientific formula routinely used to determine the patient's care. In the final analysis, this research shows that even in this day and age, doctor judgment continues to be critical in patient care".

Neither Dr. Hueb nor Dr. Pereira reports any disclosures in connection with this research. MASS II was funded by an internal grant from the University of São Paulo Heart Institute.


Posted by: Julia    Source

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