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FROM THE EDITORIAL DESK                                                                             Editorial Committee
                                                                                                    Dr. Rajiv Malhotra
    Dr. (Prof.) Renu Madan            Dear Friends,                                                 Dr. Renu Madan
                                                                                                    Dr. Anil Dhall
           Sr. Consultant & HOD       The month of September has not only brought with it a         Dr. Sandeep Singh
MD (Pathology) PDCC (Oncopathology),  deluge of monsoon-related illness but also a feeling of       Dr. B. K. Dubey
                                      pre-festivity which began in our hospital with Eid and        Dr. (Brig.) Ashok K. Rajput
     HOD Pathology & Lab Medicine     Onam celebrations. So this 'Come September' edition has       Dr. Anupam Saha
                                      an article on a much debated topic of how to manage the       Dr. Shilpa Ghosh
                                      Coronary Artery Disease – surgically or by PTCA. Besides,     Dr. A. K. Dhar
                                      an interesting case report with remarkable results is         Dr. Dinesh Katiyar
                                      published and we have some basic facts about cataract.        Dr. Deep Dutta
                                      Our last edition had a quiz and we are glad to announce that  Dr. Sunil Kumar Mendiratta
                                      we have a winner for it. Our efficient Radiology Department
                                      has obliged us with yet another image which will tickle       Advisory Committee
                                      the diagnostician in everyone. Hope that in this wide         Dr. (Lt. Gen.) Prem P. Varma
                                      array there will be some message of use to one and all.       Dr. (Prof.) Nirmal Kumar
                                      So bonne lecture!!!                                           Dr. Anupam Mondal
                                                                                                    Dr. Ishwar Singh
                                      Email: editor@venkateshwarhospitals.com                       Dr. Sarita Sabharwal
                                                                                                    Dr. Rakhee Gogoi

CLINICAL ARTICLES

CURRENT MODALITIES OF TREATMENT
FOR CORONARY ARTERY DISEASE –

ARE WE ON THE RIGHT PATH?

The most appropriate modality of treatment for Multivessel Coronary             rates that were very similar for both CABG and DES-treated patients. In
Artery Disease (MVD) remains controversial – whether medical treatment,         contrast, in patients with the highest SYNTAX scores (>33), reflecting the
surgical or percutaneous intervention, remains a matter of debate.              most complex disease, the SYNTAX trial clearly showed that CABG was
Coronary Artery Bypass Surgery (CABG) and Percutaneous Coronary                 the best option. As such, surgeons and interventionists have largely been in
Intervention (PCI) are both safe and established treatment modalities           agreement that PCI is a reasonable option for the lowest-risk group, while
of Invasive revascularisation for patients with Coronary Artery Disease         surgery is the clear winner for the highest-risk patients.
(CAD). Each patient should be analysed according to the risk factors, the
Coronary Anatomy, comorbidities and long-term anticipated results before        In intermediate-risk patients the two-year results showed a trend towards
deciding the treatment modality to be offered. It is important to realise that  improved outcomes with CABG, but no statistically significant differences,
both therapies have improved tremendously since their inception. CABG           leading some to argue that PCI could still be considered for patients with
can now be performed off-pump (OPCABG) and with minimally invasive              an intermediate SYNTAX score-particularly if they had left main disease,
keyhole techniques not requiring Sternotomy (MIDCAB). PCI techniques            but not triple-vessel disease. The three-year MACCE results in these
have seen increasing use of stents in the last decade, which provide a          intermediate-risk patients, however, show that the event curves have
rapid, less invasive option for management of CAD with quicker hospital         continued to separate, reaching 27.4% for DES-treated patients and 18.9%
discharge and return to daily activities.                                       for the CABG-treated patients, a difference that now reaches statistical
                                                                                significance (p=0.02).
The most awaited and acclaimed study for its ‘non-bias’ is the SYNTAX
Synergy between PCI with TAXUS and Cardiac Surgery trial. SYNTAX was            What's clear from these three-year results, is that it is only the
an 1800-patient trial randomising patients with left main Coronary Disease      lowest-risk patients by SYNTAX score in whom both PCI and CABG can
and/or three-vessel disease to either CABG or PCI using the Taxus DES           be considered to be reasonable options. The 'enduring lesson' from
(Drug Eluting Stent). At one year, PCI failed to meet the pre-specified margin  SYNTAX is that revascularisation for chronic, complex coronary disease
of non-inferiority against CABG, after the primary end point Major Adverse      needs to be individualised to
Cardiac and Cerebral Events (MACCE) occurred significantly more often           coronary anatomy, comorbidities and
among PCI-treated patients than among CABG-treated patients, driven by          patient preferences.
repeat procedures in the PCI group. For the 'harder' end point of death/
stroke/MI, rates were almost identical between the two groups; the stroke       It is important to tailor the needs
rate was higher in the CABG-treated patients. Two-year results, presented       of the patient and decide stent or
at last year's European Society of Cardiology meeting, showed MACCE             surgery in an unbiased manner
rates continuing to diverge, still driven by higher repeat-revascularisation    where the winner is the patient.
rates and a signal of increased MI among PCI-treated patients.
                                                                                              Dr. Sandeep Singh
Stroke, which at one year had significantly favoured the DES-treated
patients, was no different between the two groups by three years and nearly                               MS, M Ch, FICS, FACCS
identical between years one and two and between two and three. MI rates,                                    Director & HOD,
which had numerically favoured the CABG-treated patients at one year and
had reached statistical significance by the two-year mark, continued to be      Cardio Thoracic & Vascular Surgery
significantly lower in CABG group from year two to three and cumulatively
were significantly lower in the CABG-treated patients over three years, with
an absolute difference of 3.5%.

For the analysis of outcomes according to baseline SYNTAX
score-developed to characterise Complex Coronary Vasculature in patients
with high-risk left main and/or three-vessel disease at both one and two
years, the lowest-risk patients by SYNTAX score (score of 0-22) had MACCE
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