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European Heart Journal 2004 25(24):2180-2182; doi:10.1016/j.ehj.2004.10.018
Copyright © 2004 by the European Society of Cardiology.
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Editorial

Cardiac revascularization of the medically refractory elderly patient: it is TIME to pay the piper

Douglass A. Morrison*

Department of Cardiology, SAVAHCS and the University of Arizona, 3601 S Sixth Ave., Tucson, AZ 85723, USA

* Correspondence to: Douglass A. Morrison, MD, PhD, Department of Cardiology, SAVAHCS and the University of Arizona, 3601 S Sixth Ave., Tucson, AR 85723, USA. Tel.: +1 5207921450x5510; fax: +1 5206294636 (E-mail: douglass.morrison@med.va.gov).

The first 10% of the full text of this article appears below.

This editorial refers to "Cost-effectiveness of invasive versus medical management of elderly patients with chronic symptomatic coronary artery disease" {dagger} by J. Claude et al. on page 2195

'...the value of our expectations always signifies something in the middle between the best we can hope for and the worst we can fear?...' Jacob Bernoulli1

It is appropriate that the first 'trial-based analysis demonstrating the cost-effectiveness of angioplasty relative to medical therapy'2 should come from Basel, Switzerland.3–5 Switzerland is the first home to angioplasty.6 Basel was home to the Bernoulli family, who made countless seminal contributions to quantitative thinking about risk versus benefit. Of all the Bernoulli contributions, none has had more influence than the concept of utility, the notion that the risk of an event must include not only its mathematical probability, but also some measure of the desire for, or aversion . . . [Full Text of this Article]

Point one: Consider the potential clinical benefit before either the risk or cost

Point two: The emphasis on coronary anatomical features, to the exclusion of physiological function, in coronary revascularization is 'outdated'

Point three: The epidemiology of our time emphasizes the importance of including elderly and co-morbid patients in revascularization trials, and the risks implicit in treating such patients 10

Point four: Much of the information in the figures of clinical effectiveness versus cost can be inferred from the early versus late costs and charges data


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