Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3840_Библиотеки_им_академика_М_И_Перельмана

Although this is an important study that demonstrates the safety and efficacy of the tested techniques, several major limitations limit its generalizability to unselected patientswith bifurcation lesions. The most important of these limitations is that only 18% of eligible patients with bifurcation lesions were recruited into this trial. Although the reasons for this selection are not clear, themost plausiblescenario is thatoperators excluded patients whom theybelieve were not good candidates for one of the techniques. This issue is of prime importance in treatment of bifurcation lesions because the various EDS techniques are not interchangeable (i.e., it is unlikely that one technique is better than allother techniques in all lesions and acrossall ranges of operator experience). For the time being, the choice of technique should be driven by the bifurcation morphology and operator experience.

2. critically appraise the “evidence” underlying the current practice guidelines recommenda-

4. Discuss the elements of a contemporary approach to clinical decision making in light of the

in reflecting the extent of uncertainty in the literature because at the end it is still promoted as “evidence.” Although it is true that RCTs are often the best we can do to increase scientific certainty, and do to an extent,the applicability of these trials,and by extension the clinical prac­tice guidelines, to individual patients is fraught with uncertainty. This uncertainty stems from whether the patient was adequately represented in the trial, whether the choice of endpoints weighs eventsproportionally toits impact on patientwell-being, whether the underlying power calculation assumptions reflect reality, andfinally whether the technology and expertise usedin the trialare similar tothose at thetime of patient’sencounter. Inbrief, despite theadmirable role of clinical practice guidelines in attempting to provide a sense of certainty in making clinical decisions, we continue to practice medicine in an environment of inescapable uncertainty. This assertion is not meant to suggest that guidelines have no practical value in clinical decision making, but rather that the process has to allow for clinical and scientific judgment to be used by those who ultimately put the recommendations into clinical practice. In other words, fram­ing a clinical decision as “evidence-based” does not absolve the physician from using clinical judgment. There are disclaimers in the guidelines that try to convey this sentiment, but are lost in the translation from print documents into practice.

the results of four small and three moderate-sized trials of patients with stable angina and significant CAD conducted in the 1970s. Altogether, 2649 patients were randomized to CABG or to an initial strategy of medical therapy. Of note, patients with ULMCAD made up only 6.6% (150 patients) of the study population and the presence of ULMCAD was not a prespecified element for analysis. In this analysis, there was a significant relative risk reduction in mortality with CABG of about 66% at 5 years with the benefit extending to 10 years.

However, this isnot the wholestory.One of themore frequently quoted studiesin support of CABG over medical therapy is the CASS (Coronary Artery Surgery Study). CASS enrolled asymptomatic orminimally symptomatic patients. Inthis registry, 1484 patientswith ULMCAD underwent CABG (n =1153) or medical therapy (n = 331) and were followed for up to 16 years (6). Patients undergoing medical therapy in this registry were at higher risk than those under­going CABG, and in this older era, CABG surgery may have been denied surgery due to older age and increased surgical risk. Although the overall median survival for CABG patients was