Clinical judgment and treatment options in stable multivessel coronary artery disease : Results from the one-year follow-up of the MASS II (medicine, angioplasty, or surgery study II)

• Published in: Journal of the American College of Cardiology Vol. 48; no. 5; pp. 948 - 955
• Main Authors: PEREIRA, Alexandre C, LOPES, Neuza H. M, SOARES, Paulo R, KRIEGER, Jose Eduardo, DE OLIVEIRA, Sergio A, CESAR, Luiz A. M, RAMIRES, Jose A. F, HUEB, Whady
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Science 05-09-2006; Elsevier Limited
• Subjects: Aged; Angina Pectoris - epidemiology; Angioplasty, Balloon, Coronary; Biological and medical sciences; Cardiology; Cardiology. Vascular system; Cholesterol; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease - complications; Coronary Artery Disease - therapy; Coronary heart disease; Coronary vessels; Decision Making; Drug Therapy; Female; Follow-Up Studies; Heart; Heart attacks; Humans; Incidence; Male; Medical sciences; Middle Aged; Myocardial Infarction - epidemiology; Predictive Value of Tests; Stents; Survival Analysis; Ventricular Function, Left; Prognosis; Angioplasty; Instrumentation therapy; Cardiovascular disease; Instrumental dilatation; Coronary heart disease; Long term; Phlebology; Mass; Medicine; Follow up study; Surgery; Tumor; Circulatory system; Cardiology
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2005.11.094

This study examined the predictive power of clinical judgment in the incidence of cardiovascular end points in a group of individuals with multivessel coronary artery disease (CAD) followed up in the MASS II (Medicine, Angioplasty, or Surgery Study II).
There is still no consensus on the best treatment for patients with stable multivessel CAD and preserved left ventricular function.
Preferred treatment allocation was recorded for each of the 611 randomized patients in the MASS II trial before randomization. We have divided our sample according to physician-guided decision and randomization result into two categories: concordant or discordant. The incidence of the points of cardiac death, myocardial infarction, and refractory angina was compared between concordant and discordant patients.
The number of concordant individuals was 292 (48.2%), and this number was not different between the three studied treatments (p = 0.11). A significant difference (p = 0.02) was disclosed because of an increased incidence of combined end point events in discordant patients. In the multivariate Cox hazard model, clinical judgment was a powerful predictor of outcome (p = 0.01) even after adjustment for other covariates. The main subgroup explaining this difference was a significant shift toward a worse outcome in the subgroup of discordant patients who underwent percutaneous coronary intervention (PCI) (p = 0.003).
Angiographic variables were more often used in making clinical decisions regarding PCI than clinical variables, and the only independent predictor of concordance status in the PCI group was the number of diseased vessels (p = 0.01). Our data are a reminder that physician judgment remains an important predictor of outcomes.