Thread: New Study: Think You Need Bypass Surgery?

New Study: Think You Need Bypass Surgery? Not So Fast!
by Sy Kraft, B.A.

New study findings suggest that contrary to current practice, doctors and patients have time to consider bypass surgery over drug treatment alone. Open-heart surgery has an early risk of death, with nearly 5% of patients who underwent bypass surgery in the study dying within 30 days of surgery. The STICH study looked into 1,212 persons that supposedly were in line for bypass surgery and tried new methods and combinations of treatment instead of direct to the operating room.

Turns out, there are benefits in treating people with medication only, and in treating people with a combination of bypass surgery and medication. Both approaches can be effective, with risks and benefits associated with each one, rather than just surgery alone.

In the study, 41% of patients assigned to treatment with drugs alone died during the follow-up period, which averaged five years. That compared with a mortality rate of 36% among patients who received bypass surgery plus medication. The relative reduction in risk of death was 14%.

Drug regimens, including aspirin, cholesterol-lowering statins, and such blood-pressure medications as beta blockers, ACE inhibitors and angiotensin-receptor blockers, can either stave off blockages that cause heart attacks or reduce the heart's workload, easing symptoms of heart failure.

According to The Mayo Clinic, here are some medication options that can work:

* Cholesterol-modifying medications. By decreasing the amount of cholesterol in the blood, especially low-density lipoprotein (LDL, or "bad") cholesterol, these drugs decrease the primary material that deposits on the coronary arteries. Boosting your high-density lipoprotein (HDL, or "good") cholesterol, may help, too. Your doctor can choose from a range of medications, including statins, niacin, fibrates and bile acid sequestrants.

* Aspirin. Your doctor may recommend taking a daily aspirin or other blood thinner. This can reduce the tendency of your blood to clot, which may help prevent obstruction of your coronary arteries. If you've had a heart attack, aspirin can help prevent future attacks. There are some cases where aspirin isn't appropriate, such as if you have a bleeding disorder of you're already taking another blood thinner, so ask your doctor before starting to take aspirin.

* Beta blockers. These drugs slow your heart rate and decrease your blood pressure, which decreases your heart's demand for oxygen. If you've had a heart attack, beta blockers reduce the risk of future attacks.

* Nitroglycerin. Nitroglycerin tablets, sprays and patches can control chest pain by opening up your coronary arteries and reducing your heart's demand for blood.

* Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These similar drugs decrease blood pressure and may help prevent progression of coronary artery disease. If you've had a heart attack, ACE inhibitors reduce the risk of future attacks.

* Calcium channel blockers. These medications relax the muscles that surround your coronary arteries and cause the vessels to open, increasing blood flow to your heart. They also control high blood pressure.

James Fang, a cardiologist at University Hospitals Case Medical Center in Cleveland, said doctors "should be comfortable" generally that surgery isn't better than the best medical therapy for the kind of patients participating in the study.

The type of surgery in question literally bypasses blood around clogged arteries to improve blood flow and oxygen to the heart. The arteries that bring blood to the heart muscle (coronary arteries) can become clogged by plaque (a buildup of fat, cholesterol and other substances). This can slow or stop blood flow through the heart's blood vessels, leading to chest pain or a heart attack. Increasing blood flow to the heart muscle can relieve chest pain and reduce the risk of heart attack.

Surgeons take a segment of a healthy blood vessel from another part of the body and make a detour around the blocked part of the coronary artery.

Cardiopulmonary bypass with a pump oxygenator (heart-lung machine) is used for most coronary bypass graft operations. This means that besides the surgeon, other surgical staff members include a cardiac anesthesiologist, surgical nurses, and a perfusionist (blood flow specialist).

During the past several years, more surgeons have started performing off-pump coronary artery bypass surgery (OPCAB). In it, the heart continues beating while the bypass graft is sewn in place. In some patients, OPCAB may reduce intraoperative bleeding, renal complications and postoperative neurological deficits (problems after surgery).

Raymond Gibbons, a cardiologist at the Mayo Clinic concludes:

"If patients are informed, they will make different decisions based on their own background. I don't think doctors should be making the judgment for them."

Sources: The Mayo Clinic and The American Heart Association

just to clarify, emergency open heart surgery for an acute MI such as left main artery occlussion during an ST or Non ST elevation MI or transmural infarction with free wall rupture etc. has clear benefits over medical therapy. In the above, they are talking about elective open heart for people who have blockages found due to stress testing/cardiac cath, not an acute MI. Then, medication/lifestyle can be just as good.