Should You Have Bypass Surgery?

Wayne Leposavic was surprised when routine tests indicated heart trouble and a subsequent angiogram found three blocked arteries surrounding his heart. The 79- year-old real-estate developer felt no chest pain and had always been healthy. So before having the coronary artery bypass graft (CABG) surgery that his cardiologist recommended, he decided to get a second opinion. And then a third.

One doctor told him that without surgery he would surely die of a heart attack. Another told him that a few standard medications would keep him alive and healthy for years to come. And a third doctor suggested angioplasty with drug-eluting stents, a procedure that mechanically widens vessels with miniature balloons and then props those vessels open with tiny mesh tubes that slowly release heart medications. First he tried the noninvasive approach: eating better, exercising more and taking the standard medications (aspirin, ACE inhibitors and beta blockers). But even as his condition improved, his peace of mind continued to deteriorate. "It was like having a sword of Damocles over my head," he says. Eventually, he gave in and had the surgery. That was three years ago. "I'm healthy and alive today," he says. "But which treatment did the trick is still a mystery."

It's a mystery even the most prominent heart doctors would be hard-pressed to solve. Americans now average nearly 500,000 bypass surgeries and more than 1 million angioplasty procedures annually, totaling more than $100 billion in medical costs. Yet, as those numbers climb, fueled by technological advances and soaring rates of coronary-artery disease (CAD), doctors and patients worry that the decision to pursue one treatment over another is based more on professional bias and patients' misperceptions than it is on sound science. Bypass surgery, angioplasty and noninvasive medical treatments each come with their own cadre of devotees, and members of one camp often don't communicate with members of the other. Meanwhile, experts say, patients often assume that surgery or angioplasty will help them live longer, even though numerous studies have failed to show any such benefit.

So how do you know which treatment is best for you? You should ask yourself (and your doctor) two questions. First: are medication and lifestyle changes sufficient or not? And second: if they aren't, which procedure is best for you? Try answering that first question before you even have an angiogram (the diagnostic procedure that probes your heart vessels for blockages), says Mark Hlatky, a professor of cardiovascular medicine at Stanford University. "Once you see the blockages, you can't resist the urge to 'fix' them."

If you do proceed with an angiogram, try not to let the results spook you. When only one or two vessels are blocked (as is true in the vast majority of cases) most studies indicate, and the American Heart Association advises, that CABG and angioplasty are probably not necessary. Replacing fats and carbs with fruits and vegetables, reducing stress, getting more aerobic exercise, and taking the right medications have proved more effective in these cases. "Those are the only measures shown to actually reverse CAD in some patients," says Preventive Medicine Research Institute founder Dean Ornish.

When all three coronary arteries are blocked or the left main artery (which supplies blood to the left side of the heart) is occluded, you will want to consider CABG or angioplasty with stenting. A recent New England Journal of Medicine study compared these two treatments in patients with severe CAD and found no significant differences in mortality or heart attack rates after one year. CABG patients faced a higher risk of stroke, but angioplasty patients were more likely to need a second procedure to open vessels that had become reclogged before the year was out.

Before you decide, make sure your cardiologist and cardiac surgeon talk to one another. Experts agree a general communication breakdown between the cardiologists who perform angioplasty and the surgeons who perform CABG has impeded the ability of each group to provide an unbiased opinion.

Be mindful of the caveats. Patients with diabetes tend to do better with CABG. Because drug-eluting stents require the use of anti-clotting medication, those with a high risk of internal bleeding should strongly consider surgery. Otherwise, it is often a matter of personal preference—surgery is more invasive, but less likely to require additional procedures in the near future. The converse is true of angioplasty with stenting.

No matter what you decide, be sure to take your medication. "I think a lot of the patients who have these procedures think they don't have to take the medications anymore," says Hlatky. "But that's just plain wrong." Angioplasty and CABG generally target vessels that are more than 50 percent blocked because those blockages are the ones that cause angina (chest pain). But drugs will treat all your blockages simultaneously, and those lesser blockages can cause heart attacks, too.

And remember: angioplasty or CABG may relieve symptoms of angina, but chances are neither will prolong your life. Only healthy lifestyle choices can do that.