The need for coronary artery surgery: expand or restrict? A European view.

I have been solicited by the organizers not to present a final solution to the problem, but to comment on controversial issues. For the indications for aorto-coronary bypass, consensus has been reached by most medical men that angina pectoris and, in selected patients, prognostic considerations are important. Controversy starts when we ask how much angina or what pattern of clinical and angiographic risk factors are required for the operative indication. It remains to be seen, whether other forms of mechanical revascularisation, such as balloon dilatation can replace surgery in large numbers of patients, who are presently treated by aortocoronary bypass. An effort has been made by physicians to make greater use of cost-benefit analysis estimates in their medical decisions, and to provide policy makers with this information. The number of aorto-coronary bypass operations in European countries varies considerably. The trend of these figures, however, is rising throughout Europe and therefore my personal answer to the crucial question in the title is: expand.