**3.2. Changing clinical patient profile**

century [1]. It was through some of this initial work, that he was able to make the first measurements of blood pressure, describe systole and diastole, characterize the volumes of the heart through wax cast work and correctly describe the function of the aortic and mitral valve [1]. Interestingly, the first human cardiac catheterization was by a Urologist by the name of Werner Forssmann [2]. He performed right heart catheterization on himself in 1929 by advancing a cannula through the left antecubital vein via cut-down access into the right atrium

The credit of the first true selective coronary angiogram and much of the initial correlations between angina pectoris and coronary anatomy has to be granted to Mason Sones, a Pediatric Cardiologist, who at the time of discovery was working out of the Cleveland clinic [3-5]. In 1958, whilst performing non-selective aortogram on a patient, Sones inadvertently engaged

The original technique of angioplasty was born out earlier work by a Vascular Radiologist by the name of Charles Theodore Dotter [6]. Andreas Gruentzig, now known as the father of modern day coronary angioplasty, learned the Dotter technique from a German Radiologist Eberard Zeitler while doing a clinical fellowship in the Radiology Department of Aggertalclinic in Engelskirchen, Germany [6]. He had adopted the Dotter concept of using the balloon approach for angioplasty [6]. After experimenting with a number of materials performed the first procedure in 1977 in a man with stenosis of his left anterior descending artery (LAD) using

The treatment of coronary artery disease can be simplified into three major therapeutic approaches: medical therapy alone, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). However, deciding on which approach is optimal for the individual patient is sometimes far from simple. This decision requires not only an in depth understanding of the evidence but also the applicability of this evidence to the individual patient considering the anatomic characteristics of the disease, the clinical context, the patient's preferences, social circumstances, and available resources [ie. local expertise and access to PCI and/or CABG]. Furthermore, because there has been evolution of all of these three approaches, interpretation of the evidence has become quite complex. Comparison of different modes of therapy (eg CABG versus medical therapy or CABG to balloon angioplasty) in the past may

Medical therapy has made remarkable advances from a time when patients may have been treated with nitrates alone to contemporary use of a combination of antiplatelets, lipid lowering therapy (statins), beta-blockers (BB) and Angiotensin Converting Enzyme- inhibitors

**2.2. Selective coronary angiography and angioplasty**

a polyvinyl chloride balloon mounted onto the Dotter catheter [6].

the right coronary artery [2].

**3. The current dilemma**

not be as relevant in the current clinical milieu.

**3.1. Advances in medical therapy**

[2].

318 Artery Bypass

Due to advances in medical therapy, patients that are now considered for revascularization are also older and have accrued more co-morbidities [9]. These co-morbidities render the interpretation of relevant symptoms more difficult. For example, in a diabetic patient with chronic obstructive lung disease (COPD), it may be difficult to distinguish between dyspnea as an anginal equivalent versus that caused by the underlying pulmonary pathology. The severity of the patients' COPD may also complicate the eligibility for CABG as a mode of revascularization [10, 11]. In fact, in a recent clinical trial comparing CABG versus PCI in complex CAD, significant burden of co-morbidities was the most common reason that patients were felt not to be suitable for CABG and hence entered into the PCI registry [9].
