Editorial Comment

Don’t You Care: You Should

Richard R. Heuser,* MD, FACC, FACP, FeSC, FASCIInterventional CardiologistAffliated Cardiologists of Arizona, Inc.

In the review article published this month in Catheteri-zation and Cardiovascular Interventions, White et al.,discuss the objectives, design, and implications of theCARE Registry [1]. What does this mean for interven-tionists, vascular surgeons, as well as hospitals andpatients? Unlike in the past, when technology comesalong that appears to be less invasive, at least as safe, ifnot safer, less expensive with well-delineated outcomes,usually that technology is embraced. Treatment regimesevolve. An example is the treatment of peptic ulcer dis-ease. Osler’s textbook of medicine, The Principles andPractice of Medicine, states ‘‘. . . the treatment of gastriculcer diseases includes: (a) absolute bed rest; (b) a care-fully and systematically regulated diet; and (c) medicinalmeasures are of very little value in gastric ulcers, and theremedies employed do not probably benefit the ulcer, butthe gastric catarrh.’’ [2] Of course, this was acceptabletreatment in the late 19th century.

Gallbladder disease has traditionally been treatedwith an open surgical procedure, but over the last decade,endoscopic removal has been the treatment of choice andis accepted as standard in most cases. This is without anyrandomized trials.

As interventional cardiologists, it seems that we haveto achieve a higher standard. Interventional cardiologyhas been hit pretty hard over the last several years,including issues of stent thrombosis, possible late throm-bosis, and possible risk involved with drug eluting stentsover and above bare metal stents. The COURAGE Trial,comparing PTCA and optimal medical therapy vs. opti-mal medical therapy, even questioned whether we shouldbe doing angioplasty at all in patients with stable angina[3]. A number of us, myself included, felt that after theSAPPHIRE Trial, comparing carotid artery stenting withthe use of an embolic protection device to endarterec-tomy, showed convincingly in high-risk patients who hadbeen randomized between surgery and embolic protec-tion with stenting, there was a significant reduction inmorbidity [4]. In fact, this pivotal trial demonstrates thatpatients undergoing carotid artery stenting who are highrisk experience lower rates for periprocedural stroke,

death, cranial nerve palsy, and myocardial infarctioncompared with a carotid endarterectomy [2]. However,this still did not satisfy the regulatory agencies, and in2004 when we finally achieved approval so we couldtreat a large number of patients we see with carotid arterydisease, we were surprised to see how limited the reim-bursement options were in these patients. Recently, stud-ies from Europe with physicians with minimal training incarotid stenting have even questioned the conclusionsfrom SAPPHIRE [5].This is why the CARE Registry is imperative. Even

though there have much larger number of patients fol-lowed with independent neurologic evaluation who havebeen treated with carotid stenting compared with theirsurgical counterparts, this data set will help us not only tobe able to know what the best therapy is, but perhapsactually get paid for these procedures which ultimatelyaffects, not only physicians, but the most important partof the puzzle, and that is the patient. Therefore, weshould ‘‘CARE’’ what this registry will show us.

REFERENCES

1. White CJ, Anderson HV, Brindis RG, et al. The Carotid Artery

Revascularization, and Endarterectomy (CARE) Registry: Objec-

tives, Design, and Implications. Catheter Cardiovasc Interv 2008;

71:721–725.

2. Osler W. The Principles and Practice of Medicine. New York D:

Appleton and Company; 1892. Special Edition Copyright

� 1978 The Classics of Medicine Library, Division of Gryphon

Editions, Ltd.

3. Boden, BE, O’Rourke, RA, Teo KK, Hartigan, PM, Maron DJ,

et al., Optimal medical therapy with or without PCI for stable

coronary disease. N Engl J Med 2007;356:1503–1516.

4. Yadav, JS, Wholey MH, Kuntz RE, Pierre MS, et al., Protected

carotid-artery stenting versus endarterectomy in high-risk patients.

N Engl J Med 2004;351:1493–501.

5. The SPACE Collaborative Group. 30-day results from the

SPACE trial of stent-protected angioplasty versus carotid endar-

terectomy in symptomatic patients: A randomized non-inferiority

trial. Lancet 2006;368:1239–1247.

*Correspondence to: Dr. Richard Heuser, 1331 N. 7th Street, Suite

400, Phoenix, AZ, 85006. E-mail: rheuser@affcard.com

Received 29 February 2008; Revision accepted 6 March 2008

DOI 10.1002/ccd.21576

Published online 14 April 2008 in Wiley InterScience (www.

interscience.wiley.com).

' 2008 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 71:726 (2008)