Camron-Stanford House The last surviving Victorian home on Lake Merritt, with period interior. Docent-led tours available. Call for hours. $3-$5. 1418

Intervention cardiologists do not fully agree with the new study. Dr P C Rath of Apollo Hospitals, Hyderabad, says that there are many things unsaid in the new study.

This study does not reflect real world scenario as only select group of patients (only 10 percent, which is 3071 of 35539 patients) were included in the study.

Most patients who were enrolled had normal heart muscle function.

A large number of patients who were initially on medical treatment subsequently underwent PCI/CABG for relief of their symptoms.

Patients who were on PCI group had significantly higher symptom relief and significantly better quality of life score than medical therapy group.

Patient on intensive medical therapy achieved excellent control of their lipids, diabetes and blood pressure which is practically difficult to achieve in majority of patients in day today practice.

The result of trial would not affect the interventional cardiologist practice pattern because the ACC/AHA guidelines on stable angina also recommend that patients with stable angina who are asymptomatic should undergo revascularisation when they have either a Left Main disease or they have LV Dysfunction or if they have very high risk criteria on noninvasive testing suggesting significant myocardium at jeopardy.

When CASS/ECSS/VA study results were published (which compared Medical therapy vs CABG), they did not show benefits in asymptomatic people. Without LMCA or LV dysfunction/ Proximal LAD disease, it was thought CABG will decline but it did not happen. Because from a patient’s point of view, a procedure or treatment is recommended not only to improve the symptom but also to relieve the symptoms so as to improve the quality of life. Reduction in mortality and symptom relief are both important.

After an angiogram, when a patient asks ‘can I wait for PCI/ CABG’ the cardiologist had no study to substantiate while saying that ‘yes, you can wait, you can be managed with medicine without increased risk of death’. After the publication of this trial, if patient is not very high risk, then the cardiologist can tell the patient that ‘OK, you can wait and try medicine if you don’t get sufficient relief we will do PCI/CABG. This is the only change I can foresee’.

Dr C N Manjunath, Head of Cardiology Dept, Director of Jayadeva Institute of Cardiology, Bangalore, says: ‘‘When angioplasty is performed using medicated stents or drug eluting stents, there is the risk of stent thrombosis. To avoid this, the patient is put on antiplatelet therapy (blood-thinning drugs are used). However, the problem in the US was that patients would discontinue taking the medications six months after the procedure is performed, since the drugs used were expensive.’’

But in India, we continue the antiplatelet therapy indefinitely. This reduces the risk of stent thrombosis to just 1.5 to 2 percent, says Dr Manjunath. ‘‘Therefore, reports about the use of stents not reducing mortality rates is not applicable to India.’’

‘‘In addition to this, case selection also plays a crucial role. Stents can be introduced to arteries that measure 2.5 mm and above. If stenting is done to an artery that is less than 2 mm, then the risk of stent thrombosis is really high.

Considering, Indians have small caliber arteries, care should be taken before deciding to stent the artery,’’ Dr Manjunath explains.

Dr A Gopi, Interventional Cardiologist, Sagar Apollo, Bangalore, says: ‘‘There are reports that suggest that drug eluting stents do not bring down the total mortality rate. But when compared to restenosis rates after using bare metal stents, which is about 15 to 25 percent, DES brought it down to less than five percent.

‘‘But what is being noticed is that, though the rate of restenosis was brought down, some patients were having sudden myocardial infractions due to blood clots. Therefore, it is a little difficult to say which is better and which is not,’’ adds Dr Gopi.

‘‘Nevertheless, drug eluting stents play a major role as they bring down the need for a second procedure drastically. In bare metal stents, once there is a case of restenosis, a procedure has to be performed. This is not only beyond the reach of most patients, but also increases the risks of restenosis to 30 to 40 percent. So the process does not end with a second procedure.

Given this, a small increase in stent thrombosisis acceptable when compared to a second procedure with bare metal stents,’’ says Dr Gopi.