Revascularization and survival in multivessel coronary artery disease in ischemia

The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. We read with interest the commentary by Sabik and colleagues1Sabik III, J.F. Bakaeen F.G. Ruel M. Moon M.R. Malaisrie S.C. Calhoon J.H. et al.The American Association for Thoracic Surgery and Society of Thoracic Surgeons reasoning for not endorsing the 2021 ACC/AHA/SCAI coronary revascularization guidelines.J Thorac Cardiovasc Surg. 2022; 163: 1362-1365Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar regarding their reasons for not endorsing the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Coronary Revascularization Guidelines.2Lawton J.S. Tamis-Holland J.E. Bangalore S. Bates E.R. Beckie T.M. Bischoff J.M. et al.Writing Committee Members2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.J Am Coll Cardiol. 2022; 79: 197-215Crossref PubMed Scopus (46) Google Scholar As ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial investigators, we write to place some of their statements into context and to correct a factual error related to ISCHEMIA. First, while it is true that only 24% of patients who were revascularized underwent coronary artery bypass grafting (CABG), this translates to 530 patients who underwent CABG, more than any previous randomized controlled trial comparing revascularization with medical therapy.3Maron D.J. Hochman J.S. Reynolds H.R. Bangalore S. O'Brien S.M. Boden W.E. et al.Initial invasive or conservative strategy for stable coronary disease.N Engl J Med. 2020; 382: 1395-1407Crossref PubMed Scopus (929) Google Scholar Second, while the choice of percutaneous coronary intervention versus CABG was left to local heart teams, sites and cardiovascular surgeons were required to meet stringent CABG volume and quality metrics established by the trial's Optimal Revascularization Therapy Committee, of which Dr Sabik was a member. Third, there were clear recommendations for CABG detailed in the protocol developed and approved by the trial's Optimal Revascularization Therapy Committee. Fourth, contrary to the statement by Sabik and colleagues, ISCHEMIA did not demonstrate a trend toward improved survival with multivessel coronary artery disease in the initial invasive strategy group.3Maron D.J. Hochman J.S. Reynolds H.R. Bangalore S. O'Brien S.M. Boden W.E. et al.Initial invasive or conservative strategy for stable coronary disease.N Engl J Med. 2020; 382: 1395-1407Crossref PubMed Scopus (929) Google Scholar,4Reynolds H.R. Shaw L.J. Min J.K. Page C.B. Berman D.S. Chaitman B.R. et al.Outcomes in the ISCHEMIA trial based on coronary artery disease and ischemia severity.Circulation. 2021; 144: 1024-1038Crossref PubMed Scopus (55) Google Scholar The American Association for Thoracic Surgery and The Society of Thoracic Surgeons reasoning for not endorsing the 2021 ACC/AHA/SCAI Coronary Revascularization GuidelinesThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 4PreviewThe American Association for Thoracic Surgery (AATS) and The Society of Thoracic Surgeons (STS) have decided not to endorse the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) Coronary Artery Revascularization Guidelines1 as they do not reflect our interpretation of the best treatment for patients with ischemic heart disease. The AATS and STS have three areas of concern with the guidelines as written: (1) downgrading of coronary artery bypass grafting (CABG) in the treatment of three-vessel coronary artery disease (CAD); (2) lack of recognition of the superior long-term benefits of CABG vs percutaneous coronary intervention (PCI) in decreasing repeat reintervention and postprocedural myocardial infarctions; and (3) awarding a Class of Recommendation (COR) I to the radial artery as a CABG conduit. Full-Text PDF Reply: The forced correlation between ISCHEMIA and the inaccurate CABG recommendations of the 2021 American College of Cardiology/American Heart Association/Society for cardiovascular Angiography coronary revascularization guidelinesJTCVS OpenVol. 10PreviewWe appreciate the Letter to the Editor by Maron and colleagues regarding our manuscript addressing reasons for not endorsing the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Coronary Revascularization Guidelines.1-3 First, we congratulate the authors of the ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) report on a well-conducted study providing reassuring data regarding the safety of initial conservative management of patients with low atherosclerotic burden and normal ventricular function. Full-Text PDF Open Access

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