I would say that some ambiguity about “candidate for either CABG or PCI” improves the external validity of this result, since on a practical level we actually know who these pts are. The Cath doc has rendered an opinion. You have a surgeon review the films. You’re not dealing with CTO’s or very high Syntax score anatomy. And you’re not dealing with poor overall surgical candidates. If both say they would take the case, then that’s a BARI-2D pt. If one of them says they wouldn’t take the case, then you also have your answer.
Btw this study and Freedom, it is unfortunate there has not been a 3 arm study of PCI vs CABG vs med therapy in this population.
Your points are well taken. However, based on our experience, operators occasionally have differing opinions regarding the candidacy of certain patients for PCI or CABG.
We agree that including a medical therapy arm in the FREEDOM trial would have provided valuable information.
You correctly point out the important practical limitation to this study, “One potential limitation of this trial is that the authors included patients who were candidates for either PCI or CABG without providing enough details on what makes someone not a candidate. This lack of clarity limits physicians' ability to fully understand which patients would have been suitable for inclusion.”
Why not address this in the form of a letter to the editor of NEJM inviting the authors to respond.
On a broader level, journals might provide a section for authors of accepted articles to provide an addendum, even many years later, providing answers to important questions not asked by the reviewers and not answered in the original publication.
My point is that a request for more information that will help practicing physicians and their patients benefit from a published study is always timely. Perhaps editors at NEJM and similar journals should reassess any policy to the contrary. They owe this not only to physicians and future patients but also to the subjects who in good faith volunteered to participate in a randomized trial.
In the meanwhile, perhaps Cardiology Trials could contact the original authors and convince them to provide the missing data.
The New England Journal of Medicine does allow comments on articles they publish and gives authors the opportunity to respond but this has to be happen, per their current policy, within a few weeks after the article publication.
Another study showing that nobody knows how to slow the progress of atherosclerosis or prevent any of its complications. How many times do we need to rediscover the wheel? I suspect a lot---as long as the funding continues. There is some evidence that interventional therapy can be beneficial in unstable angina and early acute infarction, but it is not overwhelming. It seems pretty clear that "therapy" in the setting of stable CAD is pretty useless---whether it be interventional or medical. The same is probably true for Type 2 Diabetes that I would argue is a fictional disease (along with "pre-diabetes").
I would say that some ambiguity about “candidate for either CABG or PCI” improves the external validity of this result, since on a practical level we actually know who these pts are. The Cath doc has rendered an opinion. You have a surgeon review the films. You’re not dealing with CTO’s or very high Syntax score anatomy. And you’re not dealing with poor overall surgical candidates. If both say they would take the case, then that’s a BARI-2D pt. If one of them says they wouldn’t take the case, then you also have your answer.
Btw this study and Freedom, it is unfortunate there has not been a 3 arm study of PCI vs CABG vs med therapy in this population.
Your points are well taken. However, based on our experience, operators occasionally have differing opinions regarding the candidacy of certain patients for PCI or CABG.
We agree that including a medical therapy arm in the FREEDOM trial would have provided valuable information.
You correctly point out the important practical limitation to this study, “One potential limitation of this trial is that the authors included patients who were candidates for either PCI or CABG without providing enough details on what makes someone not a candidate. This lack of clarity limits physicians' ability to fully understand which patients would have been suitable for inclusion.”
Why not address this in the form of a letter to the editor of NEJM inviting the authors to respond.
On a broader level, journals might provide a section for authors of accepted articles to provide an addendum, even many years later, providing answers to important questions not asked by the reviewers and not answered in the original publication.
My point is that a request for more information that will help practicing physicians and their patients benefit from a published study is always timely. Perhaps editors at NEJM and similar journals should reassess any policy to the contrary. They owe this not only to physicians and future patients but also to the subjects who in good faith volunteered to participate in a randomized trial.
In the meanwhile, perhaps Cardiology Trials could contact the original authors and convince them to provide the missing data.
Thank you for your suggestion, Neil.
The New England Journal of Medicine does allow comments on articles they publish and gives authors the opportunity to respond but this has to be happen, per their current policy, within a few weeks after the article publication.
Other journals may have different policies.
Another study showing that nobody knows how to slow the progress of atherosclerosis or prevent any of its complications. How many times do we need to rediscover the wheel? I suspect a lot---as long as the funding continues. There is some evidence that interventional therapy can be beneficial in unstable angina and early acute infarction, but it is not overwhelming. It seems pretty clear that "therapy" in the setting of stable CAD is pretty useless---whether it be interventional or medical. The same is probably true for Type 2 Diabetes that I would argue is a fictional disease (along with "pre-diabetes").
As you indicated and discussed on this substack, an initial invasive approach for stable CAD does not improve hard outcomes.
We will be reviewing medical therapy for stable CAD in the upcoming months.