Coronary revascularization, when it needs to be done it needs to be done.

Rapid advances in the fields of diagnostic and therapeutic cardiology have led to an increase in health care costs. This has resulted in cost curtailing measures imposed by health care managers, based on assumptions that utilization of these methods do not provide commensurate increases in health benefits (over-use). To control the presumably spiralling costs of health care, practice guidelines are rapidly being formulated and implemented, against which the decision process of the physicians is assessed. These methods, developed to check over-use, have rarely been used to report under-use. In this issue Filardo et al., using a prospective observational cohort, report on patients undergoing revascularization. The patients had lower mortality rates (4·8% vs 10·6%, P=0·001) than those not undergoing surgery or PTCA for what was an appropriate indication for revascularization, based on the use of the RAND Corporation Appropriateness Method. The results were unchanged after adjusting for risk factors (adjusted OR=0·48, 95% CIs 0·30–0·77). Coronary revascularization, either by CABG or PTCA, has been proven unequivocally to improve survival in selected patients, especially in those with triple vessel disease and depressed left ventricular function (CABG), and also to improve symptoms as compared to medical treatment. These results are further strengthened by the report of Filardo et al. who also described improved survival in patients who received revascularization. The authors concentrated on mortality data only. However, it would have been useful to know what was the clinical status of the surviving patients with or without revascularization. This information could have been obtained by telephone as reported in a similar study by Kravitz et al.. Further information could have been provided by relatives of patients. This would have provided insight into the cause of deaths, as it is unclear whether patients with increased mortality without revascularization had contraindications to an