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March 2, 2005

Medical vs Surgical Management of Left Main Coronary Artery Disease—Reply

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2005;293(9):1060-1061. doi:10.1001/jama.293.9.1061-a

In Reply: We agree that since the time that seminal studies established the superiority of coronary bypass surgery over medical therapy, significant advances have been made in the medical management of atherosclerotic coronary artery disease (CAD). Dr Modest cites the impact of nitrates, β-blockers, platelet inhibitors, calcium channel blockers, and statins in contemporary practice. However, nitrates, β-blockers, and aspirin were part of the pharmacopoeia when the studies comparing bypass surgery with medical management were performed. Calcium channel blockers, while approved for management of hypertension and symptomatic stable angina, have not been shown to improve prognosis in patients with CAD.1 No one can doubt the impact that statin therapy has had on the treatment of CAD, but even high-dose statin therapy with profound reductions in low-density lipoprotein cholesterol does not result in significant regression of coronary atherosclerosis.2 Concomitant with advances in medical therapy have been improvements in surgical technique and outcome, especially the widespread use of the internal mammary conduit.3 The issue is not whether improvements in pharmacotherapy have changed outcome in patients with left main CAD, but whether this has narrowed the difference in outcome between bypass surgery and medical therapy.

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