Switzerland Reports Žcourant normal in interventional cardiology, 30 years after inventing it

Abstract

Inthisissue,theWorkingGroupofInterventionalCar-diologyoftheSwissSocietyofCardiologyreportsaboutactivitiesininterventionalcardiologyintheyear2007,30yearsaftertheworld’sfirstcaseofcoronaryangio-plasty on September 16, 1977, atthe University Hos-pital of Zurich (considered to be the starting point ofinterventionalcardiologyasadiscipline).The authors have to be congratulated on providing asuccinctreportregardingexciting,yetatthesametimemundaneactivities.Theseactivitiesareconsideredtobeexcitingbecausetheyturnseverelyhandicappedpa-tients and patients at life-threatening risk into nor-mallyfunctioningindividualswithinamatterofhours,but are also considered to be mundane because theyhavelongbecomeanintegralpartofdailymedicallifeatallinstitutionsthathouseacardiologyunitbothinthecountryandaroundtheworld.Anaggingtwo-yeardelayhasplaguedthesetraditionalannualreportsfromtheirinitialonein1989[1]inspiteoftheintroductionoftheInternet,digitaldataanaly-sis,andonlinepublicationproductionoverthepast20years.Ithastobepossibletopublishsuchdatanolaterthanearlyintheyearbeingreportedon+2,preferablyaround the middle of the year being reported on +1.TheAustriansleadtheway.They,too,havenotreachedthe goal of publishing data the subsequent year [2],however they do include on-site audits of the salientfigures.ThisisnotyetpartoftheSwissreports.Infact,there is still even ablack spot in the Swiss statistics,withtheLindenhofSpitalinBernprovidingnofigures.A dent in the ever growing number of catheter-basedpercutaneouscoronaryinterventions(PCI)hasreachedSwitzerlandsimultaneously,buttoalesserdegreethantherestoftheworld.Thefactorsforthisarementionedintheworkinggroupreport.Randomisedtrialsshow-ing comparable results of conservative medical treat-mentinstablecoronaryarterydiseasetothoseofPCIhave been published time and time again. The mostprominent one (COURAGE trial)[3] was distributedandpublishedthatparticularyear.ItblendedinwiththeMASS-IItrial[4],thePETtrial[5],theFAMEtrial[6],andmorerecentlytheBARI-2Dtrial[7].Allthesetrialsanalysegroupsofpatientswithstablecoronaryarterydiseaserandomisedtoeitherinvasivetreatmentoroptimalmedicaltherapy,butfocusmerelyonhardclinicalendpointsandthestabilityofthesit-uation a few years after randomisation. Coronary ar-terydiseaseisanuncontestedkiller.However,itkillsinsidiouslyandveryslowly.Whilethisisablessingforpeopleafflictedwithit,itisaproblemwhenitcomestoassessingrespectiveformsoftreatmentoverashortpe-riodoftime.Thesimplefactthatapatientwithacoro-nary artery lesion is alive and doing fairly well a fewyearsafterdiagnosis,withouthavingundergonerevas-cularisation, proves nothing.A similar patient who isalso alive and well at the same time of follow-up buthas had his problem fixed must be better off.A timebomb with the trigger set late is still a ticking timebomb and is not proved innocuous merely by the factthatsometimehaspassedwithoutthebombgoingoff.Defusing or removing the time bomb upon detectionmakesperfectsense.TheSWISSI-IItrial[8],aSwissproductlikePCI,andameta-analysiscarriedoutbyaMunichgroup[9]lookatthe10-yearfollow-upofconservativetreatmentandPCI.TheyfoundthatmanytimebombsleftalonehavegoneoffduringthattimeandthatPCIclearlyprevails.Butarewereallysurprisedbythis?AnotherfactorfortheslowingdownofPCIgrowthmaybeequallyinstrumental.Incontrasttocommonbelief,the steep increase in PCI numbers over the past20yearsstemsmuchmorefromtheearlydiagnosisofcoronaryarterydisease(anincreaseinthenumberofinvasive facilities) and expanding of indications toearlydiseaseandoldpatients),thanfromtakingcom-plexcasesawayfromcardiacsurgeons.Oncetheearlyinvasive diagnosis of coronary artery disease has be-comecommonplacewithinacountrysuchasSwitzer-land, the PCI numbers level off as the occurrence ofcoronaryarterydiseaseisstable,ifnotdecreasing.Figure1showsthatwemaybesubjectingthecorrectpercentageofpatientstocoronaryrevascularisationorperhaps even still falling short of this percentage. ItcomparestheannualnumbersofPCIandcoronaryar-terybypassgrafting(CAGB)permillioninhabitantsinSwitzerland,Austria, and Germany, against a back-