The results of SYNTAX trial are interesting but not suprising...and are related to previous trials comparing CABG with PTCA.

I think that we don't take into account the psycological impact of an open heart surgery and we must try to evaluate other situations to select the proper revascularization method such as the need to be ready quickly back to work, age, gender, diabetes and the future need of medication, although most patients need Aspirin, beta blockers, Statins and maybe other antihypertensive drugs.

An important issue is if the patient is going to be sent to surgery during the next year because of the withdrawl of Clopidogrel (in the PTCA group).

The patient must be part of the final decision.

I am personally impressed with the PCI outcomes, particularly in light of the total length and number of stents and the frequent LM stenting. I wonder whether the inability to establish noninferiority of PCI is equivalent to establishing the superiority of CABG for the composite endpoint. Probably not, due to power considerations. The whole composite endpoint approach including repeat TVR likely biased against noninferiority.

I also have difficulty with the meta-analysis in JACC. The COURAGE trial is the largest and provided the best medical therapy. I think it stands on its own. A recent JACC "state of the art" piece appeared somewhat biased in my opinion toward intervention.