—In regard to the letters by Folland and Bernstein et al, we acknowledged in our article that this was indeed a select population. Had the patients not, however, sought a second opinion, each would have undergone coronary angiography. That this population is representative of the overall practice of coronary angiography is underscored by our reference to Topol et al,1 who reviewed some 2000 patients undergoing angioplasty—two thirds of whom had never undergone exercise stress testing and 72% who were deemed to have stable angina pectoris. In the Angioplasty Compared to Medicine (ACME) trial referred to by Folland, there was a slight increase in exercise tolerance and relief of symptoms among those undergoing PTCA, but one has to ask at what cost? Among the 105 patients randomized to angioplasty, 20 had an unsuccessful procedure, two required emergency bypass surgery, five experienced an acute myocardial infarction, and 16 underwent
Graboys TB, Lown B, Blatt CM, Lampert S. Second-Opinion Trial in Patients Recommended for Coronary Angiography-Reply. JAMA. 1993;269(12):1504–1505. doi:10.1001/jama.1993.03500120041015
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