Although long retired from clinical practice, it is still very interesting to hear these discussions between three thoughtful and intelligent cardiologists. In this field meaningful research will always be limited by the low occurrence of hard endpoints and I appreciate the fact that you always take that into account. It is difficult, if not impossible, to reach definitive conclusions in a gradually progressive disease process like atherosclerosis that is punctuated by acute episodes of MI and stroke. One of the problems with comparing hard endpoints such as mortality in studies that are done years apart is that those differences could also be due to changes in the logistics of emergency care and/or management in the CCU. I think this was a factor 30 years or so ago when paramedic services and in-field cardioversion became more widespread. Having started practice in the late 1970s when bypass surgery was practically automatic for any discovered coronary disease (without any solid evidence of benefit), it is sobering to see that much of the more recent literature shows little or no benefit for surgery over medical management. Further evidence that things that "make sense" may not always prove to be true.
Although long retired from clinical practice, it is still very interesting to hear these discussions between three thoughtful and intelligent cardiologists. In this field meaningful research will always be limited by the low occurrence of hard endpoints and I appreciate the fact that you always take that into account. It is difficult, if not impossible, to reach definitive conclusions in a gradually progressive disease process like atherosclerosis that is punctuated by acute episodes of MI and stroke. One of the problems with comparing hard endpoints such as mortality in studies that are done years apart is that those differences could also be due to changes in the logistics of emergency care and/or management in the CCU. I think this was a factor 30 years or so ago when paramedic services and in-field cardioversion became more widespread. Having started practice in the late 1970s when bypass surgery was practically automatic for any discovered coronary disease (without any solid evidence of benefit), it is sobering to see that much of the more recent literature shows little or no benefit for surgery over medical management. Further evidence that things that "make sense" may not always prove to be true.