The ageing world population faces a coming pandemic of high-risk @entity453 ( @entity453 ). @entity1 with @entity453 have 3 therapeutic options, which are based on objective clinical outcome: medical therapy and risk factor modification (Medicine), and 2 forms of revascularization, coronary artery bypass graft surgery (CABG), and percutaneous coronary intervention (PCI). More than 50 large (>100 @entity1 ), multicenter, prospective, randomized clinical trials (RCT) have compared these treatment options in terms of clinical benefits and @entity1 risks. The randomized trials which demonstrated hard outcome (survival, @entity583 , @entity64 ) benefits from statins, angiotensin-converting enzyme inhibition and @entity2405 have all been completed subsequent to the publication of most Medicine versus revascularization trials. These medical therapies, plus @entity117 , beta-blockers, and risk factor modification, should be made available to @entity1 regardless of the decision to revascularize, or the decision by what means (CABG or PCI). This review integrates the information from these trials, comparing the clinical benefits against the risks inherent in the 3 therapeutic options. The results of our review show that: trials of medicine versus revascularization (either CABG or PCI) support the revascularization paradox, in that the @entity1 at highest risk of adverse outcome, from @entity741 , have a hard outcome benefit (survival, @entity583 , or @entity64 ) from revascularization. This paradox, first seen in the Medicine versus CABG trials of the 1970s, is evident in the trials comparing fibrinolysis and other medicines, with primary PCI for ST-elevation @entity583 ( @entity583 ). The paradox is evident in the conservative versus invasive strategy trials of non-ST-elevation @entity583 and @entity1459 , where the benefit of revascularization occurs only in high-risk subsets. The paradox often results in sicker @entity1 , who have more to gain from revascularization, being denied it because of the elevated perception of risk (comparable to a reperfusion paradox in ST-elevation @entity583 , where @entity1 most likely to benefit from thrombolytics are denied them because of the perception of risk). Trials that compared medicine with revascularization for the treatment of @entity583 support the use of PCI as the preferred early stabilization strategy (90% of all PAMI trial @entity1 ). The majority of the PCI versus CABG trials enrolled populations that were at relatively low risk for @entity63 clinical events. These trials demonstrated few hard outcome (survival, @entity583 , or @entity64 ) differences between CABG and PCI. On the basis of the results obtained the following conclusions may be drawn: medicines are the primary options for stable, low-risk @entity453 , and should be given to all @entity453 @entity1 . Medically refractory is a useful high-risk marker of potential benefit from revascularization. CABG continues to be the complete revascularization option for @entity1 with multivessel, multi-lesion @entity453 , in part because of its application to chronic occlusions. PCI is the acute stabilization method of choice for @entity1 with on-going @entity63 and @entity583 , especially among @entity1 with hemodynamic compromise, and/or major comorbidity.

Balancing benefit against risk in the choice of therapy for XXXX . Lesson from prospective, randomized, clinical trials of percutaneous coronary intervention and coronary artery bypass graft surgery.

@entity1 :: ('9606', 'Species') :: ['Patients', 'patients', 'patient'] @entity64 :: ('MESH:D020521', 'Disease') :: ['stroke'] @entity583 :: ('MESH:D009203', 'Disease') :: ['acute MI', 'myocardial infarction', 'MI'] @entity2405 :: ('MESH:D058924', 'Chemical') :: ['thienopyridines'] @entity63 :: ('MESH:D007511', 'Disease') :: ['ischemia', 'ischemic'] @entity117 :: ('MESH:D001241', 'Chemical') :: ['aspirin'] @entity1459 :: ('MESH:D000789', 'Disease') :: ['unstable angina'] @entity741 :: ('MESH:D017202', 'Disease') :: ['myocardial ischemia'] @entity453 :: ('MESH:D003324', 'Disease') :: ['CAD', 'coronary artery disease']
@entity453 :: (MESH:D003324,Disease) :: ['coronary artery disease']
