- Email: [email protected]
Stents versus angioplasty
Figure: Indices of inflammation before and after G-CSF OP1=colectomy (elective operation). AB1=co-amoxiclav. OP2=relaparotomy+intraoperative lavage. AB2=cefmenoxime/amikacin/metronidazole. OP3=planned relaparotomy+intraoperative lavage. IL-6=interleukin-6. CRP=C-reactive protein. there is
consensus
antibiotics, lavage not, and
so
about the
protocol-what types of lavage, planned relaparotomy or addition, the timing of procedures and
or no
on.5 In
investigations needs to be recorded with obsessive care. We thank F Weitzel and M Bartscherer for
help in cytokine
K P Reimund, *W Lorenz, I Celik, A Bauhofer, B R Seitz, M Rothmund
assays.
Greger,
*Institute of Theoretical Surgery, Clinics of General Surgery and Internal Medicine, of Marburg, Klinikum Lahnberge, 35033 Marburg, Germany
Philipps-University
1 2
3
4
5
Eidelman LA, Sprung CL. Why have new effective therapies for sepsis not been developed? Crit Care Med 1994; 22: 1330. Bone RC, Balk RA, Cerra FB, et al. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20: 864-74. Lorenz W, Weitzel F, Sitter H. Consensus-assisted development of a study protocol on sepsis: an important difference from previous randomized trials. Theor Surg 1994; 9: 63-67. Mertelsmann R, Kanz L. Hematopoietic growth factors in cancer chemotherapy: an overview. In: Cvitkovic E, Droz JP, Armand JP, Khoury S, eds. Handbook of chemotherapy in clinical oncology, 2nd ed, 1993: 1-2. Roberts R. Sepsis clinical trials-the next generation: an FDA perspective. Fifth Vienna Shock Forum. Shock 1995; 3 (suppl): 1-1.
Stents
versus
angioplasty
SiR-Goldberg and colleagues,
in their June 17 commentary, conclude that coronary stents have improved the efficacy of angioplasty. In my view they do not, however, give a true perspective on how much less effective this combined intervention remains compared with coronary artery bypass surgery-at least in the short term. What does a 20-30% relative reduction in restenosis really mean? I have looked at medium-term results of bypass surgery (CABG) versus angioplasty (PTCA) from comparative trials. For 100 patients treated there were (after 2-3 years) 32 fewer repeat procedures in the CABG group, 28 fewer patients were on antianginal medication, and 10 more patients were free of angina after CABG than after PTCA. I have also examined the results of bypass surgery and stenting compared with angioplasty. For 100 patients treated (after 6 are correct to
months, the duration of follow-up of the major clinical trials there were 6 fewer revascularisations (ie, and 7 fewer patients with angina after stenting, and 28 fewer revascularisations and 17 fewer patients with angina after CABG than after PTCA. Clearly there is still a long way to go before the short-term to medium-term results of angioplasty match those of bypass surgery. Since the cost of angioplasty without stenting reaches parity with that of bypass surgery within 3 years it is also difficult to see how the routine use of stents can be costeffective at their current price.
of elective PTCA or
John
stenting) CABG)
McMurray
Western General
Hospital, Crewe Road, Edinburgh EH4 2XU, UK
Transmural myocardial ischaemia during dobutamine stress echocardiography SiR-Dobutamine stress echocardiography (DSE) is used increasingly in the diagnosis of ischaemic heart disease. The test has an acceptable safety profile, but major complications such as acute myocardial infarction and ventricular fibrillation can occur in patients with angiographic coronary artery disease (CAD).’ Although dobutamine may cause coronary vasoconstriction in theory, no case of transmural myocardial ischaemia due to coronary artery spasm in association with DSE in patients with normal coronary angiograms has been reported. A 69-year-old black woman had chronic stable angina of Canadian Angina Class II for 3 months. She never had angina at rest. Her baseline electrocardiogram showed sinus rhythm, left axis deviation, and poor progression of R waves across the precordial leads. DSE was performed. The baseline echocardiogram was normal. The dose of dobutamine infusion was increased to 40 )ig kg ’min-’ and 0-2 mg of atropine was administered. The patient achieved a maximum heart rate of 131 beats per min. She experienced severe substernal chest pain, the electrocardiogram showed 2 mm ST segment elevation in leads II, III, AVF, and V4-V6, and the echocardiogram showed inferior wall hypokinesia. After discontinuation of dobutamine and treatment with glyceryl trinitrate, the chest pain and the ST segment 383
consensus
antibiotics, lavage not, and
so
about the
protocol-what types of lavage, planned relaparotomy or addition, the timing of procedures and
or no
on.5 In
investigations needs to be recorded with obsessive care. We thank F Weitzel and M Bartscherer for
help in cytokine
K P Reimund, *W Lorenz, I Celik, A Bauhofer, B R Seitz, M Rothmund
assays.
Greger,
*Institute of Theoretical Surgery, Clinics of General Surgery and Internal Medicine, of Marburg, Klinikum Lahnberge, 35033 Marburg, Germany
Philipps-University
1 2
3
4
5
Eidelman LA, Sprung CL. Why have new effective therapies for sepsis not been developed? Crit Care Med 1994; 22: 1330. Bone RC, Balk RA, Cerra FB, et al. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20: 864-74. Lorenz W, Weitzel F, Sitter H. Consensus-assisted development of a study protocol on sepsis: an important difference from previous randomized trials. Theor Surg 1994; 9: 63-67. Mertelsmann R, Kanz L. Hematopoietic growth factors in cancer chemotherapy: an overview. In: Cvitkovic E, Droz JP, Armand JP, Khoury S, eds. Handbook of chemotherapy in clinical oncology, 2nd ed, 1993: 1-2. Roberts R. Sepsis clinical trials-the next generation: an FDA perspective. Fifth Vienna Shock Forum. Shock 1995; 3 (suppl): 1-1.
Stents
versus
angioplasty
SiR-Goldberg and colleagues,
in their June 17 commentary, conclude that coronary stents have improved the efficacy of angioplasty. In my view they do not, however, give a true perspective on how much less effective this combined intervention remains compared with coronary artery bypass surgery-at least in the short term. What does a 20-30% relative reduction in restenosis really mean? I have looked at medium-term results of bypass surgery (CABG) versus angioplasty (PTCA) from comparative trials. For 100 patients treated there were (after 2-3 years) 32 fewer repeat procedures in the CABG group, 28 fewer patients were on antianginal medication, and 10 more patients were free of angina after CABG than after PTCA. I have also examined the results of bypass surgery and stenting compared with angioplasty. For 100 patients treated (after 6 are correct to
months, the duration of follow-up of the major clinical trials there were 6 fewer revascularisations (ie, and 7 fewer patients with angina after stenting, and 28 fewer revascularisations and 17 fewer patients with angina after CABG than after PTCA. Clearly there is still a long way to go before the short-term to medium-term results of angioplasty match those of bypass surgery. Since the cost of angioplasty without stenting reaches parity with that of bypass surgery within 3 years it is also difficult to see how the routine use of stents can be costeffective at their current price.
of elective PTCA or
John
stenting) CABG)
McMurray
Western General
Hospital, Crewe Road, Edinburgh EH4 2XU, UK
Transmural myocardial ischaemia during dobutamine stress echocardiography SiR-Dobutamine stress echocardiography (DSE) is used increasingly in the diagnosis of ischaemic heart disease. The test has an acceptable safety profile, but major complications such as acute myocardial infarction and ventricular fibrillation can occur in patients with angiographic coronary artery disease (CAD).’ Although dobutamine may cause coronary vasoconstriction in theory, no case of transmural myocardial ischaemia due to coronary artery spasm in association with DSE in patients with normal coronary angiograms has been reported. A 69-year-old black woman had chronic stable angina of Canadian Angina Class II for 3 months. She never had angina at rest. Her baseline electrocardiogram showed sinus rhythm, left axis deviation, and poor progression of R waves across the precordial leads. DSE was performed. The baseline echocardiogram was normal. The dose of dobutamine infusion was increased to 40 )ig kg ’min-’ and 0-2 mg of atropine was administered. The patient achieved a maximum heart rate of 131 beats per min. She experienced severe substernal chest pain, the electrocardiogram showed 2 mm ST segment elevation in leads II, III, AVF, and V4-V6, and the echocardiogram showed inferior wall hypokinesia. After discontinuation of dobutamine and treatment with glyceryl trinitrate, the chest pain and the ST segment 383