Lifelong Health by Dr. David Lipschitz

Diabetes is clearly a national epidemic, occurring far more frequently today than it did 10 years ago. Most frighteningly, the increase in diabetes has brought along much higher incidences of elevated cholesterol, elevated triglycerides, coronary artery disease and heart attacks.

Until now, conventional wisdom indicated that the most effective and best approach to treating coronary artery disease in diabetics is open-heart surgery or coronary artery bypass grafting, or CABG. Unfortunately, the conventional wisdom was based on research conducted many years ago, before the development of better approaches to treatment and medical management of both conditions. Experts throughout the field are beginning to question whether invasive therapy is the best course of action.

There are several reasons a diabetic could be a candidate for an invasive cardiac procedure. First, the patient may have presented with an acute heart attack or have coronary artery disease associated with heart failure or a reduced ability to pump blood. Here either CABG or percutaneous coronary angioplasty, or PCA, is still the treatment of choice. However, for many diabetics with coronary artery disease, the illness is stable. Patients may present with some shortness of breath or chest pain on exertion (angina), but this does not affect normal functioning.

Sadly, many stable and asymptomatic diabetics still have had invasive cardiac treatment. Not infrequently, a heart CT scan or stress test diagnoses coronary artery disease. This is followed by an angiogram, and depending on the finding, a PCA or CABG is performed. Until now, many physicians could claim that this approach is justified in diabetics.

Because of new advancements in care, the National Institutes of Health sponsored a study comparing the results of open-heart surgery, angioplasty and medical management in patients with adult-onset diabetes. The results were published recently in The New England Journal of Medicine.

A total of 2,368 patients with diabetes and heart disease were examined. These patients were overweight, had coronary artery disease, and usually did not require insulin to regulate their blood sugars.

Remarkably and unexpectedly, the survival rate five years later was the same in patients treated with CABG or the more conservative PCA as it was in those treated with medications alone. Even the number of significant cardiac events was no different in the two groups.

Based on that seminal finding, we can say with great certainty that in patients with stable heart disease — with or without diabetes — invasive procedures do not prolong life or reduce the risk of heart attack. The major benefit of any invasive procedure is the relief of significant symptoms, including severe shortness of breath and worsening chest pain that does not respond to medical management. For asymptomatic patients who do not have an acute problem, treatment with medications should always be attempted first.

Incredibly, more than 50 percent of patients with coronary artery disease — with or without diabetes — do not receive appropriate medical management. That is a huge mistake.

If you are a diabetic and have coronary artery disease, you must take the medicines to reduce your risk of a heart attack or heart failure. That includes an aspirin to prevent clotting in the coronary arteries and a beta blocker (atenolol) and an ACE inhibitor (lisinopril). In addition, blood sugar must be controlled adequately. Also, high blood pressure must be treated, and cholesterol must be brought to target levels.

Patients who can prevent the more invasive therapies can also avoid major side effects and complications. A CABG carries a risk of death, ranging from 2 to 7 percent, and strokes (2 to 3 percent). Significant memory loss occurs in about 50 percent of patients undergoing bypass grafting. And the risk is particularly high in those older than 70 and in diabetics.

The evidence is clear: Expensive invasive procedures should be the last, rather than the first, choice — even in patients battling the complicated condition of diabetes. There always will be reasons for performing CABGs and PCAs, but every patient should be truly educated and empowered to ensure that any recommended therapy is appropriate, prudent and safe.

Dr. David Lipschitz is the author of the book "Breaking the Rules of Aging." To find out more about Dr. David Lipschitz and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate Web page at www.creators.com. More information is available at www.DrDavidHealth.com.

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