Cardiac revascularization of the medically refractory elderly patient: it is TIME to pay the piper

This editorial refers to "Cost-effectiveness of invasive versus medical management of elderly patients with chronic symptomatic coronary artery disease" † by J. Claude et al. on page 2195 '…the value of our expectations always signifies something in the middle between the best we can hope for and the worst we can fear?…' Jacob Bernoulli1 It is appropriate that the first 'trial-based analysis demonstrating the cost-effectiveness of angioplasty relative to medical therapy'2 should come from Basel, Switzerland.3–5 Switzerland is the first home to angioplasty.6 Basel was home to the Bernoulli family, who made countless seminal contributions to quantitative thinking about risk versus benefit. Of all the Bernoulli contributions, none has had more influence than the concept of utility , the notion that the risk of an event must include not only its mathematical probability, but also some measure of the desire for, or aversion to, that event, that the individual risk-assessor experiences.1The English word 'risk' is derived from the Italian risicare , to choose or to dare.1 What patient group is better suited to take the concept of utility and provide evidence of its relevance to medical choices than the chronically ill, co-morbid elderly population? If there is one patient group that understands that even a modest likelihood of being left unable to care for oneself may be too high, or that there are medical outcomes worse than death (for example, disabling stroke), that patient group is the chronically ill, co-morbid elderly.The Swiss TIME investigators have demonstrated both the clinical and cost effectiveness of revascularization versus optimal medical therapy, in stable patients, precisely because they chose to study patients who had:*Correspondence to: Douglass A. Morrison, MD, PhD, Department of Cardiology, SAVAHCS and the University of Arizona, 3601 S Sixth Ave., Tucson, AR 85723, USA. Tel.: +1 5207921450x5510; fax: +1 5206294636 (E-mail: douglass.morrison{at}med.va.gov).