Ann Thorac Surg 2004;78:2026-2027
© 2004 The Society of Thoracic Surgeons
INVITED COMMENTARY
Verdi J. DiSesa, MD
Section of Cardiac Surgery, The Chester County Hospital, 701 East Marshall St, West Chester, PA 19380, USA
vdisesa{at}cchosp.com
This article reports a retrospective examination of independent factors increasing the likelihood of referral for coronary artery bypass graft (CABG) surgery in a cohort of 688 patients with non–ST-segment elevation acute coronary syndromes admitted to a single tertiary care center over a 30-month period. A test cohort was used to generate a prediction model, which then was tested in a validation cohort. The model was specific but relatively insensitive, correctly identifying only 50% of the patients referred for surgery. The authors argue that overall the model should correctly predict management in 76 of 100 patients. They suggest that the predictive score could be used to guide medical therapy (particularly the use of clopidogrel) and to inform precatheterization discussion in patients admitted with acute coronary syndromes.
The authors are correct that clinical protocols for the managment of acute coronary syndromes often include the use of clopidogrel. Furthermore, this drug is usually prescribed before the coronary anatomy, and therefore the most appropriate clinical management, is known. Patients, therefore, may be exposed to a drug that otherwise would not be prescribed and may go to catheterization with unrealistic expectations that surgical intervention can be avoided. Finally, as the authors note, exposure to clopidogrel may increase the risk of postoperative bleeding and cause otherwise avoidable delays in surgical therapy. It would most likely be useful, therefore, to have a tool such as the one proposed that could predict the likelihood of referral for CABG surgery in patients with acute ischemic syndromes.
The authors have proposed one such tool. The model they derived depends on clinical variables determined to be independent risk factors for CAGB. These factors, TIMI risk score, the presence of chronic heart failure (CHF), and peripheral vascular disease have the advantage of ready availability to clinicians caring for patients with acute coronary syndromes. The details of the TIMI risk score may not be familar to all readers of the Annals, and the labels "CHF" and "peripheral vascular disease" certainly can mean different things to different people. Nonetheless, the authors have used a valid scientific method (logistic regression) and simplified its application so that it may serve as a useful adjunct to clinical decision making. Such a contribution should be commended and encouraged. This approach, after all, is the conceptual basis for evidence-based clinical practice, an endeavor that cardiac surgeons helped pioneer.
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Development of a Score to Predict the Need for Coronary Artery Bypass Graft Surgery in Patients With Non-ST Segment Elevation Acute Coronary Syndromes
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Ann. Thorac. Surg. 2004 78: 2022-2026.
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