Evaluating risks and benefits in coronary revascularisation—a very imperfect art?

There have been major changes in the delivery of services to patients with coronary disease over the last two decades. These include primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) and an early invasive strategy for those with non-STEMI acute coronary syndromes (ACS). In these settings patients undergo angiography with a view to immediate angioplasty (so-called “follow-on” or “ad-hoc” angioplasty) or early coronary artery bypass grafting (CABG). Chest pain clinics identify patients who need early angiography and these and other elective patients are frequently listed for a potential follow-on procedure. These changes have made revascularisation units more efficient, with greater patient throughput and reduced hospital bed-days. In the United Kingdom they have played a major part in significantly reducing waiting times for procedures. However, this increased efficiency has its challenges. One of the most important is the issue of obtaining informed consent. Decisions should be based on an estimate of the risk of a procedure followed by the risk of the condition as modified by treatment, compared with the risk of the condition on medical treatment alone.1 Estimates of risks and benefits are dependent on a very complex amalgam of many clinical variables and not just the extent of ventricular dysfunction and pattern of coronary disease. The patients cannot be fully advised before coronary angiography but they should at least be introduced to the concepts behind decision-making and the possible outcomes following the angiogram. We perform revascularisation procedures to improve symptoms or improve prognosis. In the emergency setting PCI is usually the first-line approach as it is effective in a situation where the risks of CABG are high. After presenting with a non-STEMI ACS, patients stabilised on medical therapy are willing to undergo angiography as they understand that the effort is to try and prevent …