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Editor’s Perspective Questioning Conventional Wisdom Harlan M. Krumholz, MD, SM I Downloaded from http://circoutcomes.ahajournals.org/ by guest on June 18, 2017 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 59 60 Circ Cardiovasc Qual Outcomes 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. Downloaded from http://circoutcomes.ahajournals.org/ by guest on June 18, 2017 Disclosures 9. References 10. None. 1. Warren JR, Marshall BJ. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet. 1983;1:1273–1275. 2. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a 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 11. 12. 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: 2109 –2122. 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 J Med. 2007;356:1503–1516. 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 Cardiovasc Qual Outcomes. 2009;2:49 –54. Weintraub WS, Cohen DJ. The limits of cost-effectiveness analysis. Circ 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: 2795–2804. Eagle KA, Gurm HS. We Were Fishing for TROUT and We Caught a CARP. Circ Cardiovasc Qual Outcomes. 2009;2:61– 62. 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 Circulation: Cardiovascular Quality and Outcomes is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2009 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-7705. Online ISSN: 1941-7713 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circoutcomes.ahajournals.org/content/2/2/59 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation: Cardiovascular Quality and Outcomes can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. 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