To the Editor.
—The recent article by Dr Mason and colleagues1 illustrates the advantages of decision analysis in the absence of randomized clinical trials for evaluating the appropriate care of patients with significant coronary artery disease undergoing major vascular surgery. It highlights the multiple confounding factors that would limit the ability to perform such a trial, and it emphasizes the need for large sample size to obtain meaningful data. However, their conclusion that coronary angiography and revascularization are not the optimal strategy except in rare circumstances seems unjustified.We have recently published a similar decision analysis and concluded that the optimal decision was extremely sensitive to local factors such as morbidity and mortality for both coronary and vascular surgery.2 The primary difference between our analysis and that of Mason et al is the choice of probability of mortality for the base case. For mortality from abdominal aortic aneurysm
Fleisher LA, Lehmann HP. Preoperative Cardiac Evaluation and Perioperative Monitoring for Noncardiac Vascular Surgery. JAMA. 1995;274(21):1671–1672. doi:10.1001/jama.1995.03530210025013