Less Than Perfect Procedure

G iven the high prevalence of coronary artery disease in Western countries, selection of the optimal therapeutic strategy for individual cardiac patients has become an issue of utmost costbenefit importance. During the past two decades, large clinical trials have established the respective roles of medical treatment versus coronary artery bypass surgery in the management of patients with coronary disease. In 1978, Grintzig et al's report of their early experience with coronary angioplasty1 opened the era of interventional cardiology, and since then, angioplasty has emerged as a major tool in the armamentarium for treating coronary artery disease. Initially, the use of angioplasty was restricted to selected patients with angina pectoris refractory to medical treatment. However, as interventionists became more skilled and equipment more sophisticated, indications for angioplasty were rapidly extended to include patients with moderate or mild angina. This led to an exponential growth in the number of angioplasties performed over the past decade, and in 1991, more than 300,000 procedures were performed in the United States alone at an estimated cost of $7.2 billion, representing roughly 1% of the total annual expenditure for health care.