Most of the thousands of patients who undergo costly surgery to relieve chronic heart pain do not live any longer than patients treated by drugs, according to an article in a leading medical journal.
The article, in the current New England Journal of Medicine, is based on a three-year study of 596 patients in 13 Veterans Administration hospitals. It found that 87 per cent of patients treated with drugs were alive after three years compared with 88 per cent who underwent coronary artery by-pass surgery, the most frequently performed heart operation in the United States.
Controversy within the medical profession concerning coronary artery by-pass surgery, which costs an average of $12,500, has been growing as the number of bypass operations - an estimated 70,000 will be performed in 1977 - has increased.
The procedure involves removal of a portion of a vein from a patient's leg and use of the vein to construct a detour around an obstruction or blockage in one of the arteries carrying blood away from the hears. Supporters of the procedure contend that it has proven to be a superior way of reducing or eliminating severe heart pain or angina.
Critics of the procedure contend that in many cases it is being performed unnecessarily, that the patient could be treated as effectively with drugs or that no proof exists that the patient's life expectancy will be improved by the operation.
The VA study excluded a class of patients representing anywhere from 3 to 12 per cent of the total number of bypass operations performed in the United States - those with left main coronary artery disease - because it has already been demonstrated that their survival is enhanced if they receive coronary artery bypass surgery.
The articel does not address the more difficult to measue issue of whether surgery is a superior method to drugs in relieving pain caused by angina. According to Dr. Marvin L. Murphy, one of the article's principal authors, data is still being gathered on the relative effectiveness of medical and surgical treatment to relieve symptoms.
As far as mortality is concerned, the article states, "there is no difference in survival of the medical [drug-treated] from that of the surgical group . . ."
Dr. W. Gerald Austen, president-elect of the American Heart Association, said that he supports controlled studies to determine the effectiveness of surgical procedures but that the VA study was faulty because the mortality rate for the surgical patients was three times as high as it should be.
An editorial in the same issue of the signed by Eugene Braunwalsd, one of the foremost heart specialists in the United States, noted that some advocates of bypass surgery are performing the operation on patients without symptoms or pain in the hope, "largely without objective supporting evidence at present," that the operation will prolong the patient's life or diminish the risk of a subsequent heart attack.
"If the notion that this operation does indeed prolong life is generally accepted," Braunwald wrote, it could lead to performing the operation on "the many hundreds of thousands in whom such disease would surely be discovered. This course would escalate the annual national cost into many billions of dollars, which, in turn, could result in a radical redistribution of medical-care resources."
With that prospect in mind, Braunwald said, continued support of research like the VA study and a larger study being conducted by the National Heart, Lung and Blood Institute of the National Institutes of Health "appears to be a particularly wise investment . . .