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BEST—When a Study Falls Short of Its Acronym

      Two recent studies in the New England Journal of Medicine attempted to cast some light on the question how percutaneous coronary intervention (PCI) compares to coronary artery bypass grafting (CABG) but arrived at somewhat different conclusions.
      • Park S.J.
      • Ahn J.M.
      • Kim Y.H.
      • Park D.W.
      • Yun S.C.
      • Lee J.Y.
      • Kang S.J.
      • Lee S.W.
      • Lee C.W.
      • Park S.W.
      • Choo S.J.
      • Chung C.H.
      • Lee J.W.
      • Cohen D.J.
      • Yeung A.C.
      • Hur S.H.
      • Seung K.B.
      • Ahn T.H.
      • Kwon H.M.
      • Lim D.S.
      • Rha S.W.
      • Jeong M.H.
      • Lee B.K.
      • Tresukosol D.
      • Fu G.S.
      • Ong T.K.
      BEST Trial Investigators
      Trial of everolimus-eluting stents or bypass surgery for coronary disease.
      • Bangalore S.
      • Guo Y.
      • Samadashvili Z.
      • Blecker S.
      • Xu J.
      • Hannan E.L.
      Everolimus-eluting stents or bypass surgery for multivessel coronary disease.
      As Robert Harrigton pointed out in the accompanying editorial,
      • Harrington R.A.
      Selecting revascularization strategies in patients with coronary disease.
      randomized trials such as the Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease (BEST)
      • Park S.J.
      • Ahn J.M.
      • Kim Y.H.
      • Park D.W.
      • Yun S.C.
      • Lee J.Y.
      • Kang S.J.
      • Lee S.W.
      • Lee C.W.
      • Park S.W.
      • Choo S.J.
      • Chung C.H.
      • Lee J.W.
      • Cohen D.J.
      • Yeung A.C.
      • Hur S.H.
      • Seung K.B.
      • Ahn T.H.
      • Kwon H.M.
      • Lim D.S.
      • Rha S.W.
      • Jeong M.H.
      • Lee B.K.
      • Tresukosol D.
      • Fu G.S.
      • Ong T.K.
      BEST Trial Investigators
      Trial of everolimus-eluting stents or bypass surgery for coronary disease.
      remain the gold standard to test a hypothesis although they are not entirely free of pitfalls. Indeed, the BEST trial exemplifies some issues incurring with noninferiority trials and composite outcomes combining safety and efficacy. From a narrow statistical perspective, BEST was a futile attempt in establishing noninferiority of PCI compared with CABG in patients with multivessel disease on the primary composite of death, myocardial infarction (MI), or revascularization (notably excluding stroke). The difference was driven by the established advantage of CABG preventing revascularizations,
      • Windecker S.
      • Stortecky S.
      • Stefanini G.G.
      • da Costa B.R.
      • Rutjes A.W.
      • Di Nisio M.
      • Silletta M.G.
      • Maione A.
      • Alfonso F.
      • Clemmensen P.M.
      • Collet J.P.
      • Cremer J.
      • Falk V.
      • Filippatos G.
      • Hamm C.
      • Head S.
      • Kappetein A.P.
      • Kastrati A.
      • Knuuti J.
      • Landmesser U.
      • Laufer G.
      • Neumann F.J.
      • Richter D.
      • Schauerte P.
      • Sousa Uva M.
      • Taggart D.P.
      • Torracca L.
      • Valgimigli M.
      • Wijns W.
      • Witkowski A.
      • Kolh P.
      • Jüni P.
      Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis.
      the magnitude of which made it unlikely that PCI could be on par. From a broader clinical perspective, the question how PCI compares with CABG in terms of death, MI, or stroke remained unanswered. The premature termination of BEST
      • Park S.J.
      • Ahn J.M.
      • Kim Y.H.
      • Park D.W.
      • Yun S.C.
      • Lee J.Y.
      • Kang S.J.
      • Lee S.W.
      • Lee C.W.
      • Park S.W.
      • Choo S.J.
      • Chung C.H.
      • Lee J.W.
      • Cohen D.J.
      • Yeung A.C.
      • Hur S.H.
      • Seung K.B.
      • Ahn T.H.
      • Kwon H.M.
      • Lim D.S.
      • Rha S.W.
      • Jeong M.H.
      • Lee B.K.
      • Tresukosol D.
      • Fu G.S.
      • Ong T.K.
      BEST Trial Investigators
      Trial of everolimus-eluting stents or bypass surgery for coronary disease.
      resulted in estimates that remain imprecise and compatible with both, a relevant benefit of PCI or harm.
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