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Editor’s Perspective
Questioning Conventional Wisdom
Harlan M. Krumholz, MD, SM
I
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widely accepted as authoritative truth. The intent is to raise
important questions, address gaps in knowledge, and elevate
clinical care and healthcare policy by inquiring about the
impact of treatments on the patient. Circulation: Cardiovascular Quality and Outcomes seeks to provide a welcoming
forum for disparate views, with the stipulation that the focus
remains on the science.
Recent issues have featured articles that provide some
sense of this mission. For example, economic analyses can
provide valuable perspectives on how resources are allocated,
even as there is debate about the methodology.7,8 In this issue,
Mihaylova et al9 question conventional wisdom with a
cost-effective analysis of statin use in patients with different
vascular risk profiles. The study uses data from the Heart
Protection Study to demonstrate the dominant role of global risk
on determining the economic attractiveness of prescribing statins. The authors find that it is economically attractive to treat
based on risk of at least 10% during 10 years.
The study indicates that, in contrast to conventional wisdom, it may be better to focus on a patient’s global risk in
recommending treatment strategies. This emerging insight
questions the treat-to-target mentality—an approach that
targets a single risk factor rather than the risk of the patient as
a whole. Curiously, the treat-to-target paradigm became
dominant even as trial evidence from the Heart Protection
Study and other trials of statins for prevention focused on the
effect of a fixed dose of statin on outcomes. The trials did not
explicitly test a treat-to-target strategy. Whether the study by
Mihaylova et al will ultimately change guidelines, policies,
and practice remains to be seen, but demonstrating the
expected economic attractiveness of this approach promotes
the scientific debate.
This issue also contains an article by Garcia et al10 that
makes use of the Coronary Artery Revascularization Prophylaxis Trial, a randomized, controlled trial testing the longterm benefit of coronary artery revascularization before
elective vascular surgery.11 Although many physicians accept
the doctrine that patients with high-risk coronary disease
should undergo revascularization before elective vascular
surgery, the Coronary Artery Revascularization Prophylaxis
Trial did not identify a benefit of this strategy. In this new
contribution, the investigators focus specifically on the highest risk patients, for whom the benefits of revascularization
would be expected to be greatest. Among the patients with 2
or more risk factors and ischemia on preoperative stress
imaging, the event rate was 23%. However, the rate was no
different between those who did and did not undergo a
revascularization strategy; addressing the ischemia did not
decrease perioperative risk. The editorial by Eagle and
Gurm12 reinforces this point. Similar to the study by Mihaylova et al, this study takes aim at current practice and
guidelines and indicates that a new approach is warranted.
n science, what seems obvious may not be true, and what
is accepted as conventional wisdom, may sometimes be
based on flawed assumptions. What is more obvious than the
fact that the sun revolves around the earth? Each day the sun
rises in the eastern horizon, and we observe it moving across
the sky until it retires in the west. And yet, it is not true that
the earth is the center of the universe. Galileo de’ Galilei, the
scientist born in Pisa, was persecuted for questioning such
conventional wisdom and supporting the theory proposed by
Nicolaus Copernicus of a heliocentric universe. Ultimately,
the truth could not be suppressed.
We have many examples of progress that resulted from the
questioning of strongly held beliefs that once seemed so
obvious. Who anticipated that a gastric ulcer could be
considered an infectious disease?1 Who expected that drugs
that effectively suppressed premature ventricular beats in
patients with ischemic heart disease would cause harm?2 Who
believed that treatment strategies associated with substantial
risk reduction might be poorly adopted into practice even 10
years after the publication of the trials establishing their
efficacy?3 Who could predict that an intervention that lowered low-density lipoprotein and increased high-density
lipoprotein would increase mortality through possible offtarget effects?4 Who was ready for evidence that elective
percutaneous coronary intervention for patients with stable
heart disease would not reduce the risk of dying or prevent
heart attacks, and would be such an expensive approach to
improving quality of life?5,6
As clinician-scientists, we have a responsibility to question
conventional wisdom—to open our eyes to insight that may
be easily eclipsed by the dogma of the moment. And then, we
must provide evidence that goes beyond opinion so that the
emerging expert consensus has been thoroughly examined
and tested.
We perceive Circulation: Cardiovascular Quality and Outcomes as a vehicle to promote the dissemination of evidence that
often challenges conventional wisdom. The goal is not to
foment, dissent, or arbitrarily criticize established doctrine,
but rather to support dialogue that critically examines the
status quo and, when necessary, questions dogma that is
The opinions expressed in this article are not necessarily those of the
American Heart Association.
From the Section of Cardiovascular Medicine and the Robert Wood
Johnson Clinical Scholars Program, Department of Medicine; Section of
Health Policy and Administration, School of Public Health, Yale University School of Medicine; and the Center for Outcomes Research and
Evaluation, Yale-New Haven Hospital, New Haven, Conn.
Correspondence to Harlan M. Krumholz, MD, SM, 1 Church Street,
Suite 200, New Haven, CT 06510. E-mail [email protected]
(Circ Cardiovasc Qual Outcomes. 2009;2:59-60.)
© 2009 American Heart Association, Inc.
Circ Cardiovasc Qual Outcomes is available at
http://circoutcomes.ahajournals.org
DOI: 10.1161/CIRCOUTCOMES.109.857755
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March 2009
If you are interested in publishing the results of a study or
have concerns about the current practice of medicine that may
be deemed too contrary or far from the mainstream by other
editors and reviewers, be assured that you will find a
receptive audience at Circulation: Cardiovascular Quality
and Outcomes. If your work is done well and your conclusions follow your arguments and data, you will not be
disqualified because your conclusions are at odds with
conventional wisdom. In any era, to question the opinions held
by authoritative figures—and by doing so to illuminate truths
that are so easily obscured or ignored—requires courage. We
may not discover truths so profound as the heliocentric universe,
but we can occasionally dispel strongly held beliefs and produce
scholarship that will build a stronger foundation for clinical
decisions and healthcare policy.
5.
6.
7.
8.
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Disclosures
9.
References
10.
None.
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in active chronic gastritis. Lancet. 1983;1:1273–1275.
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randomized trial of arrhythmia suppression after myocardial infarction.
N Engl J Med. 1989;321:406 – 412.
3. Marciniak TA, Ellerbeck EF, Radford MJ, Kresowik TF, Gold JA,
Krumholz HM, Kiefe CI, Allman RM, Vogel RA, Jencks SF. Improving
the quality of care for Medicare patients with acute myocardial infarction:
results from the Cooperative Cardiovascular Project. JAMA. 1998;279:
1351–1357.
4. Barter PJ, Caulfield M, Eriksson M, Grundy SM, Kastelein JJ, Komajda
M, Lopez-Sendon J, Mosca L, Tardif JC, Waters DD, Shear CL, Revkin
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JH, Buhr KA, Fisher MR, Tall AR, Brewer B. Effects of torcetrapib in
patients at high risk for coronary events. N Engl J Med. 2007;357:
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Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ,
Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L,
Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates
ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS. Optimal
medical therapy with or without PCI for stable coronary disease. N Engl
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Weintraub WS, Boden WE, Zhang Z, Kolm P, Zhang Z, Spertus JA,
Hartigan P, Veledar E, Jurkovitz C, Bowen J, Maron DJ, O’Rourke R,
Dada M, Teo KK, Goeree R, Barnett PG; on Behalf of the Department of
Veterans Affairs Cooperative Studies Program No. 424 (COURAGE
Trial) Investigators and Study Coordinators. Cost-effectiveness of percutaneous coronary intervention in optimally treated stable coronary
patients. Circ Cardiovasc Qual Outcomes. 2008;1:12–20.
Diamond GA, Kaul S. Cost, effectiveness, and cost-effectiveness. Circ
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Cardiovasc Qual Outcomes. 2009;2:55–58.
Mihaylova BN, Briggs A, Hlatky M, Armitage J, Parish S, Gray A,
Collins R. Statin cost-effectiveness in the United States for people at
different vascular risk levels. Circ Cardiovasc Qual Outcomes. 2009;2:
65–72.
Garcia S, Moritz RE, Goldman S, Littooy F, Pierpont G, Larsen GC, Reda
DJ, Ward HB, McFalls EO. Perioperative complications after vascular
surgery are predicted by the revised cardiac risk index but are not reduced
in high-risk subsets with preoperative revascularization. Circ Cardiovasc
Qual Outcomes. 2009;2:73–77.
McFalls E, Ward H, Moritz T, Goldman S, Krupski W, Littooy F,
Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda D, Henderson W. Coronary artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:
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Eagle KA, Gurm HS. We Were Fishing for TROUT and We Caught a
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KEY WORD: Editorials
Questioning Conventional Wisdom
Harlan M. Krumholz
Downloaded from http://circoutcomes.ahajournals.org/ by guest on June 18, 2017
Circ Cardiovasc Qual Outcomes. 2009;2:59-60
doi: 10.1161/CIRCOUTCOMES.109.857755
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