To the Editor: Dr Pfisterer and colleagues1 reported that 1 year after either invasive treatment or optimized medical therapy, elderly patients with angina had similar symptoms, quality of life, and risk of death or nonfatal myocardial infarction. In contrast with their previous report of 6-month outcomes,2 the authors now report that patients who underwent medical therapy had a higher risk of later hospitalizations for uncontrolled symptoms. The end point of hospitalization seems reasonable, even though other primary and secondary prevention studies did not use it.3 - 5 Although this makes the trial less comparable with previous results, the authors did not discuss these differences.
Furthermore, the authors' use of the term "optimized medical therapy" seems questionable. Only 22% of these patients received lipid-lowering drugs, and despite the fact that all had symptomatic coronary artery disease, 23% had diabetes and 45% had hypercholesterolemia. Ideal medical management would include achieving low-density lipoprotein cholesterol of less than 100 mg/dL (<2.59 mmol/L), a blood pressure in the 130/85 mm Hg range, the discontinuation of smoking, and both exercise and dietary management. The authors did not note how often these goals were reached at the end of the 1-year follow-up. The differences in the number of hospitalizations could have been affected by appropriate aggressive medical therapy.
I am also concerned about the validity of this sample. Among the patients who underwent angiography, 11 (8%) had no disease, 19 (14%) had single-vessel disease, and 17 (13%) had left main artery disease. Together, these 47 patients (35%) should have been excluded from the study, because there is no mortality benefit from revascularization of single-vessel disease or of no vessel disease. Coronary artery bypass graft surgery is generally indicated for left main artery disease.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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