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).
OBJECTIVE
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).


BACKGROUND
There is still no consensus on the best treatment for patients with stable multivessel CAD and preserved left ventricular function.


METHODS
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.


RESULTS
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).


CONCLUSIONS
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.
Pereira
Alexandre C
AC
Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil. lbmpereira@incor.usp.br
Lopes
Neuza H M
NH
Soares
Paulo R
PR
Krieger
Jose Eduardo
JE
de Oliveira
Sergio A
SA
Cesar
Luiz A M
LA
Ramires
Jose A F
JA
Hueb
Whady
W
D000368:Aged; D000787:Angina Pectoris / Q000453:epidemiology; D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000150:complications / Q000628:therapy*; D003657:Decision Making; D004358:Drug Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology; D011237:Predictive Value of Tests; D015607:Stents; D016019:Survival Analysis; D016277:Ventricular Function, Left