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CLINICAL RESEARCH: CORONARY ARTERY DISEASE

Clinical Judgment and Treatment Options in Stable Multivessel Coronary Artery Disease

Results From the One-Year Follow-Up of the MASS II (Medicine, Angioplasty, or Surgery Study II)

Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.

Manuscript received March 3, 2005; revised manuscript received October 23, 2005, accepted November 21, 2005.

^_* Reprint requests and correspondence: Dr. Alexandre C. Pereira, Heart Institute, Av. Dr. Enéas de carvalho Aguiar, 54, 10 Andar, Bloco 2, São Paulo, Brazil. (Email: lbmpereira{at}incor.usp.br).

OBJECTIVES: This study examined the predictive power of clinical judgment in the incidence of cardiovascular end points in a group of individuals with multivessel coronary artery disease (CAD) followed up in the MASS II (Medicine, Angioplasty, or Surgery Study II).

BACKGROUND: There is still no consensus on the best treatment for patients with stable multivessel CAD and preserved left ventricular function.

METHODS: Preferred treatment allocation was recorded for each of the 611 randomized patients in the MASS II trial before randomization. We have divided our sample according to physician-guided decision and randomization result into two categories: concordant or discordant. The incidence of the points of cardiac death, myocardial infarction, and refractory angina was compared between concordant and discordant patients.

RESULTS: The number of concordant individuals was 292 (48.2%), and this number was not different between the three studied treatments (p = 0.11). A significant difference (p = 0.02) was disclosed because of an increased incidence of combined end point events in discordant patients. In the multivariate Cox hazard model, clinical judgment was a powerful predictor of outcome (p = 0.01) even after adjustment for other covariates. The main subgroup explaining this difference was a significant shift toward a worse outcome in the subgroup of discordant patients who underwent percutaneous coronary intervention (PCI) (p = 0.003).

CONCLUSIONS: Angiographic variables were more often used in making clinical decisions regarding PCI than clinical variables, and the only independent predictor of concordance status in the PCI group was the number of diseased vessels (p = 0.01). Our data are a reminder that physician judgment remains an important predictor of outcomes.

Abbreviations and Acronyms   CABG = coronary artery bypass graft surgery   CAD = coronary artery disease   HDL = high-density lipoprotein   LAD = left anterior descending coronary artery   LDL = low-density lipoprotein   MASS II = Medicine, Angioplasty, or Surgery Study II   MT = medical treatment   PCI = percutaneous coronary intervention

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