Heart Bypass Surgery

My daughter read this in the Austin American Statesman newspaper on Sunday and sent it to me. Nina Research questions value of artery-opening operations New model of heart disease indicates such aggressive measures might not be as effective as old-fashioned advice By Gina Kolata THE NEW YORK TIMES Sunday, March 21, 2004 A new and emerging understanding of how heart attacks occur indicates that increasingly popular aggressive treatments may be doing little or nothing to prevent them. Artery-opening methods such as bypass surgery and stents -- the widely used wire cages that hold plaque against an artery wall -- can open obstructed blood vessels and alleviate crushing chest pain. Stents also can rescue someone in the midst of a heart attack by destroying an obstruction and holding the closed artery open. But the new model of heart disease shows that a vast majority of heart attacks do not originate with obstructions that narrow arteries. Instead, recent and continuing studies show that a more powerful way to prevent heart attacks in patients at high risk is to adhere rigorously to what can seem like boring old advice: give up smoking, for example, and take drugs to control blood pressure, lower cholesterol levels and prevent blood clotting. Researchers estimate that just one of those tactics -- lowering cholesterol to what guidelines suggest -- can reduce the risk of heart attacks by a third, but is followed by only 20 percent of heart patients. "It's amazing, and it's completely backward in terms of prioritization," said Dr. David Brown, an interventional cardiologist at Beth Israel Medical Center in New York. Heart experts say they understand why the disconnect occurred: They, too, at first found it hard to believe what research was telling them. For years, they were wedded to the wrong model of heart disease. "There has been a culture in cardiology that the narrowings were the problem and that if you fix them the patient does better," said Dr. David Waters, a cardiologist at the University of California at San Francisco. The old idea was this: Coronary disease is akin to sludge building up in a pipe. Plaque accumulates slowly, over decades, and once it is there it is pretty much there for good. Every year, the narrowing grows more severe until one day no blood can get through and the patient has a heart attack. Bypass surgery or angioplasty -- opening arteries by pushing plaque back with a tiny balloon and then, often, holding it there with a stent -- can open an artery before it closes completely. But, researchers say, most heart attacks do not occur because an artery is narrowed by plaque. Instead, they say, heart attacks occur when an area of plaque bursts, a clot forms over the area and blood flow is abruptly blocked. In 75 percent to 80 percent of cases, the plaque that erupts was not obstructing an artery and would not be stented or bypassed. The dangerous plaque is soft and fragile, produces no symptoms and would not be seen as an obstruction to blood flow. That is why so many heart attacks are unexpected, heart experts say. A person will be out jogging one day, feeling fine, and struck with a heart attack the next. If a narrowed artery had been the culprit, exercise would have caused severe chest pain. Heart patients have hundreds of vulnerable areas with plaque, so preventing heart attacks means going after all their arteries, not one narrowed section, by attacking the disease itself. That is what happens when patients take drugs to aggressively lower their cholesterol levels, to control their blood pressure and to prevent blood clots. Yet, researchers say, old notions persist. "There is just this embedded belief that fixing an artery is a good thing," said Dr. Eric Topol, an interventional cardiologist at the Cleveland Clinic. In particular, he said, more people are getting stents. According to an analysis by Merrill Lynch, based on sales figures, more than a million stent operations will be performed this year, nearly double the number performed five years ago. Some doctors still adhere to the old model. Others say they know it no longer holds but that they sometimes end up opening blocked arteries anyway, even when patients have no other symptoms. Dr. David Hillis, an interventional cardiologist at the University of Texas Southwestern Medical Center in Dallas, explained: "If you're an invasive cardiologist and Joe Smith, the local internist, is sending you patients, and if you tell them they don't need the procedure, pretty soon Joe Smith doesn't send patients anymore. Sometimes you can talk yourself into doing it even though in your heart of hearts you don't think it's right." Hillis said he has tried to explain the evidence to patients, to little avail. "You end up reaching a level of frustration," he said. "I think they have talked to someone along the line who convinced them that this procedure will save their life. They are told if you don't have it done you are, quote, a walking time bomb."