In summary, the medical care of coronary artery disease has evolved over the past 30 years from a strategy of focusing on a prolonged bed rest for a variety of cardiac conditions, through agents relieving the work burden by reducing myocardial oxygen consumption, early reperfusion to limit infarct size, to revascularization correcting significant hemodynamic and anatomical abnormalities, and potential for gene therapy targeting specific problems. There have been many new advances in technology and with the availability of new agents, the treatment of coronary heart disease continues to significantly improve. As we continue to strive to correct many cardiovascular abnormalities using molecular biology strategies, revascularization remains an important treatment strategy in many patients with coronary artery disease. Advances in technology have provided us with an alternative approach to surgical revascularization. The optimal choice of revascularization is well-accepted in some cases, but unclear in others. The number of revascularizations continues to increase each year, particularly those with PTCA. The long-term benefits and safety of CABG have been scientifically tested, while such data are not available for PTCA or such studies are currently being conducted. Each new modality is considered promising and thought to surpass standard PTCA in providing new significant benefits. Standard PTCA has been labeled as obsolete by some; however, despite its limitations it continues to play a dominant and safe role in catheter-based revascularization. However, many questions remain to be addressed. Timing of elective revascularization, choice of procedure, and patient selection remain a daily challenge and continue to dominate the discussion among clinicians. Therefore, rigorous scientific clinical trials are needed to provide clinicians with the best data to help manage their patients. Ability to perform revascularization based on angiographic characteristics needs to be balanced by the patient's need and an expected outcome based on solid scientific evidence. The number of revascularizations inappropriately performed is not known. The data from the state of New York indicate that CABG is performed under appropriate conditions, whereas indications for PTCA were more questionable, suggesting its overutilization. Recent data also show marked regional variability in the management of AMI, particularly utilization of cardiac procedures. The regional variation was not due to clinical differences among the regions, but the use and availability of cardiac procedures were closely related. Furthermore, the marked differences in the management of AMI did not result in marked differences in short-term mortality or reinfarction rates. It has also been shown that centralization of resources, involving regional care provision, influences outcome via the volume-outcome relationship. In a recently published study, centers with low volume (<100 CABGs per year) had twice higher mortality compared to centers with high volume. A favorable angiographic appearance of lesions and the number of diseased vessels, without searching for objective evidence of ischemia, may seduce interventional cardiologists into performing 'easy' PTCAs. Current data indicate that single-vessel disease without significant ischemia on objective tests will have a good long-term outcome when managed with initial medical therapy. Furthermore, it is unclear whether revascularization provides any benefit even in patients with single-vessel disease and stable ischemia. Limited data suggest that proximal left anterior descending lesions jeopardizing a large myocardial territory may be an exception. New developments on the horizon are likely to influence the choice of revascularization procedure. Control of restenosis and avoidance of sternotomy are likely to impact upon each of the revascularization strategy utilizations. One of the main dilemmas, however, remains the optimal choice of therapy, whether medical or revascularization, for patients who are stable and have evidence of ischemia. There is also the issue of appropriate avoidance of (primarily catheter-based) revascularization for those patients where, despite appealing angiographic characteristics, there is no scientific evidence for a benefit, with a potential for harm.
