geoffrey modest medical blogs

two drug-company sponsored papers were published in new  engl  j of medicine comparing percutaneous coronary intervention (PCI) with coronary-artery bypass grafting ( CABG ), looking specifically at how the newer drug-eluting stents compare with surgery. 1. a large East Asian non-inferiority study with 27 centers randomly assigned patients with multi-vessel coronary artery disease (CAD) to PCI with  everolimus -eluting stent vs  CABG  (see  cad  cabg  vs stent  NEJM  2015  in  dropbox , or  DOI : 10.1056/ NEJMoa1415447 ). details: --880 patients were enrolled (only 1/2 of the anticipated). mean age 64, 70% male, BMI 25, 41% diabetic, 67% hypertensive, 20% current smoker, 53% hyperlipidemia. 47% with stable angina, 43% unstable angina, 9% acute MI in past 90 days; ejection fraction 59%; 77% with 3 vessel disease and 23% with 2 vessel disease (they excluded those with clinically significant ...

interventional therapy for renal artery stenosis (RAS) has been largely discredited, to my mind, since the publication of the ASTRAL study (NEJM 2009: 361:1953), which reported on 806 patients with atherosclerotic renovascular disease randomized to revascularization plus medical therapy or medical therapy alone and found that over 5 years the rate of progression of renal disease was no different, there was no difference in systolic blood pressure with minimal difference in diastolic blood pressure, but slightly more meds were used in the medication only group.  However of note, serious complications occurred in 23 patients in the revascularization group including 2 deaths and 3 amputations.  Conclusion was that substantial risks were associated with revascularization with no evident worthwhile clinical benefit. a study just reported at the American Heart Association, the CORAL trial, confirmed this earlier study (see  htn RAS stent vs med CORAL nejm  201...