BMJ 24 Mar 2007

Warning: this meta-analysis is only for single LADs. It only apples to isolated lesions of the left anterior descending coronary artery, and it only compares minimally invasive thoracic artery grafting with percutaneous stenting. So it only concerns a small subset of the alternative treatments for angina dealt with in one of the accompanying cost-effectiveness studies. Oddly enough, minimally invasive arterial grafting scores worse overall for mortality but better overall for complications such as stroke or myocardial infarction. The cost-effectiveness study for this intervention in this sub-group favours surgery, and this is roundly supported by David Taggart, a surgeon who does lots of these procedures, in his editorial.

But for the whole mass of humanity who get angina pectoris, what might be the most cost-effective option?

The investigators who did this observational study conclude that coronary artery bypass grafting is better in the long term than percutaneous intervention, especially stenting. Not for nothing has CABG become the commonest surgical operation.

I like the Change Page. This is clinical medicine at its most direct.

Here, a major change in clinical management is proposed on the basis of a single trial with a huge effect and a sound foundation in physiology and common sense. Some patients – most, perhaps – with paroxysmal atrial fibrillation should carry flecainide or propafenone and take it as and when their AF comes on. I remember proposing this to a patient soon after the trial was reported, but he stopped having his attacks anyway. Unfortunately in my copy of the BMJ the references seem to have got left unprinted.