Heart Surgery Still Rules -- Despite the Lack of Evidence

After more than three decades of doing bypasses, which is major surgery after all, and before allowing virtually every hospital to set up shop to do it, you would think that there must be plenty of data to prove that this works. But that is not the case at all. Three major studies, performed in the late 1970s and early 1980s, clearly proved that for the majority of patients, bypass surgery is no more effective than is medical treatment. These three studies were the Veterans Administration Cooperative Study (The VA Study), Coronary Artery Surgery Study (CASS) and European Coronary Artery Surgery Study (EuroCASS). These studies began in 1977, when the VA study compared those who underwent bypass surgery with the medically treated group. The unexpected results showed that, with the exception of a small subset of patients, bypass surgery did not lower the death rate or prevent heart attacks. But, instead of taking serious note of these findings and beginning to question the procedure, the cardiology community as a whole criticized the study, believing the findings were somehow wrong, and that the opposite must be true. So the National Institutes of Health, our nation's official health agency, launched the CASS study. Like the VA study, the CASS study found that the majority of patients who underwent bypass surgery did not live significantly longer or have fewer heart attacks. The EuroCASS study found similar results. If you are tempted to dismiss these studies, bear in mind that they all showed: • These were well-designed studies that appeared in major medical journals. • The cardiac medications available then were much less effective than today's medications. • These studies were done in the 1970s, but the results are not outdated. These patients have been tracked and the subject of follow-up studies that have been performed over the past two decades. These follow-up studies show the same results -- bypass surgery does not prolong life or prevent heart attacks in the majority of patients. Pitting Angioplasty Against Medical Treatment Head-to-Head One of the trials most hotly contested by angioplasty proponents was published in 2000. This was the Atorvastatin versus Revascularization Treatment (AVERT) trial, which was the first study designed to pit the new cholesterol-lowering statin drugs against the value of balloon angioplasty. The study found, to everyone's surprise, that patients treated with angioplasty did not prolong life or prevent heart attacks compared to medical therapy. In fact, the patients treated with medical therapy had a 36% reduction in heart attack risk. Then, in 2004, the progress that could be made using these newer medications become even more obvious, when a trial known as REVERSAL showed that high-dose statin therapy literally halted the progression of coronary heart disease and led to a modest decrease in the size of the atherosclerotic plaque, which is the buildup of fatty deposits in the artery wall. So Why All This Heart Surgery? Despite the evidence from these studies and others, the emphasis on heart surgery still continues. The heart intervention industry has indeed spun out of control, developing a momentum that is impossible to stop. Once bypass surgery was developed, surgical programs mushroomed, fellowship programs sprung up; cardiac anesthesiologists were trained, operating rooms built, and so on. Angioplasty spawned its own industry as well, with interventional cardiology becoming its own specialty, radiologists becoming involved, medical device companies founded to invent devices like stents and, later, drug-coated stents, and so forth. Along the way, hospitals soon discovered that the fastest way to fatten their bottom line was to expand their menu of cardiac services and everything that goes along with it, including surgical suites, radiology departments with their imaging tests, thallium scanning, CT scanning, MRI scanning -- all of this led to a significant increase in the cost of medical care. It's also not surprising that any hospital that didn't have one of these income producing cash cows found it difficult to survive without it, so it isn't surprising that every mom-and-pop hospital on every street corner of the U.S. wanted their own heart surgical program. They need it for the bottom line. Hospitals also began linking quantity to quality, so no hospital wants to be the one that does the bare minimum of procedures; if 150 heart surgeries is good, 350 is better, 1,000 is better still and so on. So that is why we're in the pickle were in today, where you have a heart-surgery industry worth billions a year with $1 out of every $5 we spend goes to health care, and its all built on a deck of cards. Who Can Benefit From Heart Surgery? Since coronary heart disease is a metabolic disorder, involving cholesterol and other risk factors, it requires a metabolic, not surgical solution. On the other hand, there are situations in which the need for heart surgery is clearly appropriate. These conditions are: • If you have a significant blockage in the left main coronary artery. This is a sub-set of patients who have been clearly shown to benefit from bypass surgery, even in the studies cited earlier in this chapter. The left main coronary artery is the main trunk artery that branches into the two arteries that supply blood to the left, or main, side of the heart muscle. A blockage in this artery is a very serious form of heart disease. • If you have severe, incapacitating chest pain that is not relieved by medication. • If you have critical blockages in three coronary arteries along with a weak heart muscle. In addition to these conditions, emergency intervention with coronary angioplasty is also warranted for people who are in the midst of having a heart attack, because urgent measures are needed to restore blood flow as quickly as possible and minimize heart damage. But for Most of Us . . . From the studies I've cited above, along with thousands of patients I've treated, it is clear that, for most people, medical treatment is better than heart surgery. Take Jack and Susan, for instance, and consider the rest of their stories. Remember Jack, the so-called "walking time bomb" who was fearful of heart surgery because his father had died undergoing a bypass? I put him on what was to become my program of aggressive prevention and now, nearly 30 years later, he's still healthy and active. In fact, a few years ago, he needed to go in for knee surgery and the doctors insisted on doing a pre-operative cardiac catheterization. The results? It showed those blockages he had when he first came to me had virtually disappeared. And, regarding Susan, who came to me after undergoing six angioplasties and fearing that she'd not live to raise her daughter, she never had to have another heart catheterization or angioplasty. She had high LDL (bad) cholesterol and low HDL (good) cholesterol, factors that never were addressed by all the procedures she'd undergone. She followed my aggressive prevention program and her cholesterol levels have been normal for years. On her last visit, she came to my office smiling, with tears of joy in her eyes, as she showed me photographs of her daughter's wedding. These experiences, along with those of the thousands of patients I've treated over the years, have convinced me that heart-surgery can be lifesaving for a small number of patients who truly need it, but it can be life threatening for the vast majority who don't. There are better ways than scalpels and stents to stay healthy.