Over the years, treatment has improved for heart attacks and coronary artery disease. With new technology, more experienced surgeons, and hospitals with highly successful diagnostic, preoperative and postoperative care, better outcomes have been seen in patients undergoing coronary artery bypass graft surgery.
In the best institutions -- with adequate numbers of operations annually -- the risks of death and serious complications have decreased. As a consequence, the number of bypasses being done is increasing significantly, and the procedure is being offered to the very old and patients with more complicated conditions.
Simultaneously, the effectiveness of the medical management of patients with coronary artery disease has improved, leading to a much lower risk of recurrence of second heart attacks, a reduction in symptoms and heart failure, and a prolongation of life. Patients are likelier to be treated successfully with medications to reduce the risk of recurrent heart attacks by positively affecting heart muscle and function, preventing platelet clotting, and the effective treatment of elevated cholesterol, diabetes and high blood pressure.
The outcomes of angioplasty -- in which a blocked artery is opened up and patency maintained using metal stents that are coated with medications -- have improved, as well, with fewer arteries re-occluding and fewer recurrent symptoms.
Because of improvements in bypass surgery, angioplasty and medical management, recent studies have provided much-needed information on the value of surgery over less invasive approaches. Today more conservative approaches are providing as good an outcome as a bypass for many of the ways in which coronary artery disease can cause harm.
Until recently, a bypass was thought to be needed in patients who had occlusion of the left main coronary artery, also known as the widow-maker, because of the high risk of death. But a study published recently in The New England Journal of Medicine showed that outcomes from angioplasty were no different from outcomes from bypasses for patients whose only significant blockage was in the left main coronary artery.
The second major indication for surgery has been blockage of three coronary vessels, a condition frequently referred to as triple vessel disease. In this case, numerous studies have shown that surgery is only beneficial over medical management for those who are not able to live a heart-healthy lifestyle or take the needed medications to prevent progression of their disease. Even for those with known heart disease who are symptomatic and have not responded to medical treatment, a bypass is no more beneficial than angioplasty, unless stents cannot be placed for technical reasons.
Another major indication for bypass was patients with coronary artery disease and a failing heart muscle that could not pump significant blood out with each contraction. Here, too, papers published in NEJM could not identify any benefit of bypass over angioplasty with medical management.
This information is very important for the health care community and patients who must be kept up-to-date and fully informed about advances in the management of coronary artery disease, the leading cause of death in men and women. In reviewing this new information, experts are offering widely differing opinions. First, they point out that there are flaws in these studies and that the studies are not definitive. But some consensus is being reached. Currently, anyone who has diabetes and severe coronary artery disease appears to benefit more from surgery, as does the patient who has blockage of the left main coronary artery, as well as many other coronary vessels.
These observations will be challenged by many. However, patients and their families must understand why surgery, angioplasty or medical management is being recommended. Always ask the surgeon and cardiologist to discuss the reasons and obtain as much information as you can about the options. Like any other group, physicians can have a more or less aggressive view of the right approach. No question, their motives are pure and they genuinely believe that their recommendation is the best for you. But opinions vary, and by being educated and empowered, you can truly understand your choices and be comfortable that decisions you and your health care team make are the best for you.
Dr. David Lipschitz's weekly column, "Lifelong Health," can be found at creators.com.