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CORONARY ARTERY DISEASE is a lifethreatening illness with an unpredictable clinical course. The intensity and quality of pain and the incidence of sudden and unexpected death creates fear in both the patient and those, including the physician, responsible for the care. The astute physician realizes that allaying the fear of the patient and his family is as important as the relief of pain. In planning therapy, however, the physician must separate his own fears and uncertainties from those of the patient and the patient's family. It is comforting to know that a patient presenting with evidence of an evolving myocardial infarction can, as discussed in the preceding article,' be taken to the operating room within 6.5 hours of the onset of pain and expect an operative mortality of only 1.3% and a late mortality of only 2.8%.1 Furthermore, for reasons which are not clear, the operation may, at least for a while, relieve the pain in 80-90% of the patients.2 3 Many physicians realize that such an activist or aggressive approach to clinical management is often more satisfying to the patient and his family than a passive or more conservative one. When serious complications or even death occur, the activist can say, "'We did everything that could have been done." Rarely, if ever, is he asked, "Was too much done?" The moment that surgery is considered, decisionmaking and responsibility become shared. In a litigious society such as ours, sharing of responsibility, to many, is very desirable and comforting. But the physician who practices both the art and the science of medicine must answer not only the question, "Can you," but also the question, "Should you?" Therefore, careful evaluation of the preceding manuscript by Phillips et al.,1 describing the use of coronary artery revascularization in the treatment of an evolving myocardial infarction, is appropriate. For surgery to have a significant role, the operation must be shown to limit and/or reduce infarct size and decrease the overall early morbidity and mortality compared with nonoperative management; it must also be shown, after several years of careful follow-up, to be more effective in postponing premature death and preventing the late complications of coronary

Emergency coronary artery revascularization of patients with acute myocardial infarction: you can ... but should you?