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  • Percutaneous Coronary Intervention or Coronary Artery Bypass Surgery for Coronary Revascularization: FAME and Fortune

    Randomized controlled trials have been the gold standard for establishing unbiased evidence to guide practice. We have often discussed strengths and limitations of trials of percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG) surgery for patients with coronary artery disease. Among our greatest concerns about trial results is the limitation of the ability to reflect current practice in a fast-moving field. Trials such as EAST and BARI studied balloon angioplasty versus surgery (clearly outdated technology). Those employing stents failed to study the most effective anti-restenotic therapies. Even drug-eluting stenting trials such as FREEDOM and SYNTAX have been criticized because of the use of early generation drug-eluting stents, and they did not employ technologies shown to be favorable to PCI such as intravascular imaging and physiologic assessment by fractional flow reserve (FFR). These trials have continued to show, in aggregate as reflected in meta-analyses, superiority of bypass surgery over PCI for patients with more extensive multivessel disease.

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