Treat the Patient, Not the Angiogram.

Abstract

Opposing Viewpoint, see p 1385 Millions of people are living with refractory angina and ischemic pain despite maximal medical therapy and are told that they have no revascularization option. The most common reason patients are told that they have no option for revascularization is the presence of a coronary chronic total occlusion (CTO).1 Although no rigorous data exist, anecdotally, the majority of CTOs are now approachable with percutaneous techniques using drug-eluting stents owing to advances in the techniques that have resulted in improved success rates regardless of anatomy (>85%) and significant relief of ischemic symptoms while maintaining adequate safety. However, attempt rates for CTO percutaneous coronary intervention (PCI) range from 1% to 16% between institutions.2 The question then arises: Among patients with a good indication for revascularization (particularly those with refractory angina and a CTO), why are so many not offered revascularization options? Here, the Canadian Cardiovascular Society Task Force on Refractory Angina provides some insights: “…[T]he nonrevascularization status will be influenced by the local expertise and operator tolerance to risk.”3 Controversy persists over what constitutes a good indication for CTO PCI. Although observational data are encouraging, it is important to acknowledge that the potential for CTO PCI to improve survival remains unproven. Until such data are available from randomized trials, asymptomatic patients can only be informed about the uncertain benefits …