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Cut Off at the Bypass

For Most People, Stents and Drugs Are Usually Safer, Better

By Marc Siegel
Special to The Washington Post
Tuesday, September 28, 2004; Page HE01

My office telephone has been ringing with patients who have heard about former President Bill Clinton's surgery this month and wonder if they might need cardiac bypass themselves. What I tell them is that careful screening for heart disease is essential, but the bypass operation, which involves sawing open the chest, is a 40-year-old procedure that is usually unnecessary.

Bypass has been shown to save lives only in certain cases, and it has never been proven to directly prevent heart attacks. It has unique risks, such as chest wall inflammation, depression and impaired thinking that may persist long-term. And though surgical technique has advanced over the years with the use of the patient's own mammary arteries and more recently with operations on the beating heart, coronary stenting and medications have also advanced greatly and have largely replaced the need for surgery.

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My patient Neal Johnston is a 64-year-old man with severe heart disease who had a heart attack 10 years ago and has since had two stents placed. He takes a cholesterol-lowering statin drug and a daily aspirin. He has refused bypass surgery several times and he continues to do well without it.

He is not alone. Another patient I know has had four coronary balloon angioplasties -- tiny inflations of blocked arteries -- over the past 15 years, the last one in 1997 with a stent that has kept the artery open ever since. He has never suffered heart damage, he remains quite active, and he, too, has refused bypass surgery on several occasions. This man is my father.

According to Fred Feit, director of interventional cardiology at New York University Medical School, the goal these days is to "come with the treatment that is least invasive." Feit said that over a recent two-day period, he catheterized 17 patients, snaking a tiny tube from the groin up into the coronary arteries. He sent only one for bypass; the rest received stents. Stents are tiny mesh cylinders are made of metal and coated these days with a drug that retards clogging. They are floated into the artery with a catheter and then snapped into place. With the latest technology, each stent appears to have less than a 10 percent chance of closing up over the first six months.

In the United States, 500,000 bypasses are still done each year, compared with more than 1 million angioplasties. But each year there are fewer bypasses and more angioplasties with stents. Over the past year, in fact, New York state has seen three times more stent procedures than coronary bypass operations.

Feit says stent placement is safer, with an in-hospital mortality rate of only 0.7 percent, compared with 1.4 to 2.1 percent for bypass surgery. In addition, bypass surgery poses other risks: heart attack immediately after surgery (3 percent), wound infection (3 percent), bleeding (3 to 5 percent) and heart arrhythmias (30 percent).

In contrast, in a 2002 study, 94 percent of the patients who were given a stent coated with the drug Rapamune, which prevents clots from forming, were free of any adverse heart events, and none experienced reclosure. The patients were followed for eight months, and follow-up data a year later continued to show open vessels in more than 90 percent of patients. Other studies have confirmed the same results.

Even most surgeons recognize that the wave of the future is away from bypass surgery, says Feit. The latest conventional wisdom on heart disease, he says, calls for a "combination of limited intervention and medication, an improved understanding of the disease process, aggressive risk factor modification and intensive medical therapy."

In fact, 15 million to 20 million people in the United States now take cholesterol-lowering statin drugs, which have just been shown to retard the development of coronary blockages or plaques to the point where a patient with clogged coronaries who seemed a sure candidate for bypass may never require any procedure at all. Lowering LDL cholesterol by 25 to 30 percent over a 10-year period has been shown to reduce the risk of cardiac events by at least 25 to 30 percent over the same period of time. Recent studies have shown that many heart patients who kept their LDL cholesterol as low as 70 with the help of the statin Lipitor actually showed some improvement in their coronary plaques.

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