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To the Editor: The Clinical Crossroads article by Drs Carrozza and Sellke¹ addresses the therapeutic options for a 69-year-old woman with disease of the left main coronary artery. Their discussion reflects state-of-the-art approaches² ; promoting these surgical interventions rests on the assumption of the therapeutic inferiority of medical management. However, the medical vs surgical management studies were largely conducted in the 1970s and 1980s, well before aggressive medical therapies were used for management of ischemia (eg, optimizing nitrates, -blockers, platelet inhibitors, and calcium channel blockers) or risk factor reduction (especially the present ability to dramatically reduce cholesterol levels).³ Current aggressive management of lipid levels leads to reduction of cardiovascular events within 6 months of initiating therapy.^4-5 It would therefore be prudent to temper the therapeutic suggestions in this case with the caveat that the efficacy of current optimal medical management in disease of the left main coronary artery is unknown.

Geoffrey A. Modest, MD
gmodest@partners.org
Boston University School of Medicine
Boston, Mass

1. Carrozza JP Jr, Sellke FW. A 69-year-old woman with left main coronary artery disease. JAMA. 2004;292:2506-2514. FREE FULL TEXT 2. Fihn SD, Williams SV, Daley J, et al. Guidelines for the management of patients with chronic stable angina: treatment. Ann Intern Med. 2001;135:616-632. FREE FULL TEXT 3. Modest G. Guidelines for the management of patients with chronic stable angina. Ann Intern Med. 2002;137:548-549. FREE FULL TEXT 4. Pitt B, Waters D, Brown WV, et al, Atorvastatin Versus Revascularization Treatment Investigators. Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. N Engl J Med. 1999;341:70-76. FREE FULL TEXT 5. Cannon CP, Braunwald E, McCabe CH, et al. Comparison of intensive and moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350:1495-1504. FREE FULL TEXT

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2005;293:1060-1061.

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