Friday, November 30, 2007

NEJM -- Management of Stable Coronary Disease -- Polling Results

NEJM -- Management of Stable Coronary Disease -- Polling Results

Management of Stable Coronary Disease — Polling Results
Susan Cheng, M.D., and John Jarcho, M.D.

In late October, we presented the case of a patient with stable coronary artery disease in Clinical Decisions,1 an interactive feature designed to assess how readers would manage a clinical problem for which there may be more than one appropriate treatment. Our patient was a 65-year-old man with hypertension, obesity, and type 2 diabetes who presented with a 2-week history of exertional angina. He underwent an exercise-tolerance test on a treadmill, along with myocardial perfusion imaging, which showed a fixed anterior defect and a reversible anterolateral defect, both of moderate size. His subsequent cardiac catheterization revealed an occluded first diagonal branch, a long lesion with 70% stenosis in the midportion of the left anterior descending coronary artery, a calcified lesion with 80% stenosis in the proximal left circumflex coronary artery, and 50% stenosis of the posterior descending coronary artery. These findings were accompanied by anterior-wall hypokinesis and an ejection fraction of 45% by left ventriculography.

Of the three management options proposed, the most popular — receiving 3282 votes (43.0% of the 7632 votes cast) — was to initiate appropriate medical therapy and follow the patient closely for adherence and efficacy. A close second, with 3066 votes (40.2% of the votes cast), was the option to initiate appropriate medical therapy and to refer the patient for coronary-artery bypass grafting (CABG). The remaining option, to initiate appropriate medical therapy and refer the patient for percutaneous coronary intervention (PCI), received 1284 votes (16.8% of the votes cast). The 7632 participants who voted were from 111 distinct countries and regions and indicated that they were physicians (84.9%), students (7.7%), or other health professionals (5.0%). Detailed results are displayed according to country in an interactive map. The percentage of participants who selected a given treatment option varied only slightly when responses were stratified by participants' self-reported locations

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