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Chocron and colleagues have reported that prior percutaneous coronary intervention (PCI) leads to a worse outcome in patients subsequently undergoing coronary artery bypass graft (CABG).1 In view of the fact that around one-third of patients with multivessel disease treated with bare metal stents will require re-intervention within a few years,2 this conclusion is potentially worrying and raises several questions. (i) Is the conclusion justifiable? (ii) Are the findings consistent with other studies in the literature? (iii) If real, what are the likely pathophysiological mechanisms? (iv) Will the findings be different drug-eluting stents? (v) What are the clinical implications for patients and the economic implications for health services?The obvious weakness of the study of Chocron et al. 1 is that it is a re-analysis of the primary end-point of the IMAGINE trial according to whether the patients had undergone PCI prior to CABG, a question which the IMAGINE trial was not designed to answer. Rather, IMAGINE was a randomized trial of the angiotensin-converting enzyme (ACE) inhibitor quinapril in 2553 subjects with preserved left ventricular function after CABG, which concluded that there was no difference in time to occurrence of the primary end-point (a composite of cardiovascular death, resuscitated cardiac arrest, non-fatal myocardial infarction, coronary revascularization, unstable angina requiring hospitalization, documented angina not requiring hospitalization, stroke, or congestive heart failure requiring hospitalization) in the active or placebo group.3 Re-emphasizing that IMAGINE was not actually designed to … *Corresponding author. Tel: +44 1865 221121, Fax: +44 1865 220244, Email: David.taggart{at}orh.nhs.uk

Does prior PCI increase the risk of subsequent CABG?