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Doctors, patients grapple with best option for coronary artery disease

TAMPA — For many heart patients, the choice is clear. They would rather have their arteries unclogged using balloons and tubes rather than a coronary bypass surgery.

Angioplasty (balloons) and stents (tubes) are far less complicated, much cheaper and typically get you out of the hospital within 24 hours, compared with a week or longer for a heart bypass. More than 1.3 million Americans go for one of those less invasive procedures, compared with about 440,000 bypasses each year.

"I don't blame them one bit," said Dr. Marc Bloom, a Tampa heart surgeon. "Because what I do to people ain't very much fun."

But is the less invasive choice always better?

Not according to the latest data, which shows that certain angioplasty and stent patients are more likely to have heart attacks, need a repeat surgery, or even die compared with those who undergo a bypass. Researchers with the SYNTAX trial, which studied 1,800 heart patients in Europe and the United States over three years, suggest that as many as 5,000 deaths each year in the United States could be avoided if patients with moderate to severe heart disease choose bypasses instead of stents.

Bloom and other doctors say because of advances in stents, an ever-growing number of heart patients are deemed suitable for either procedure, and often are given the choice. Bloom estimates that a third of heart patients fall into this gray zone.

But just because you can put a stent in someone doesn't necessarily mean it's the right thing to do, Bloom said.

Interventional cardiologist Dr. Sami Elchahal, a colleague of Bloom's at Pepin Heart Hospital in Tampa, who performs angioplasty and stent procedures, acknowledged the challenge that can arise when it's not crystal clear which option is best.

"We and our surgical colleagues don't disagree on most cases. But the people that fall into the gray zone are given options," he said.

"And an option that allows minimal time in the hospital, going home and recovering in a short period of time is attractive to any one of us."

•••

Franklin Arroyo was in the gray zone.

The 61-year-old Tampa resident experienced tightness in his chest and difficulty breathing during a round of golf on Labor Day. His cardiologist told him he could use stents to clear his blocked blood vessels. But he also suggested Arroyo consult a surgeon.

Having had a previous angioplasty in the mid-1990s, and a pair of stents inserted in 2001, Arroyo opted for the bypass this time, hoping it will spare him from a fourth procedure down the road.

"But it's frightening," he acknowledged, a day before surgery at Pepin with Dr. Ernesto Jimenez. The four-hour surgery went well, and Arroyo was scheduled to be discharged Tuesday, according to his wife, Elsie.

Coronary artery bypass grafting (or CABG, pronounced "cabbage") quickly became the standard of care for patients with coronary artery disease after the first one was performed in 1968. But the introduction of angioplasty in 1977, then stenting in the 1980s, has moved the needle toward those less-invasive options.

In a bypass, surgeons take a healthy artery or vein from the body and graft it to the blocked coronary artery. The grafted vein or artery goes around, or bypasses, the blocked portion of the coronary artery. Surgery takes several hours, can cost more than $100,000 and requires several days' recovery in the hospital.

Angioplasty involves inserting and expanding a small balloon inside the coronary artery to relieve the blockage. Stenting further helps that process, with doctors implanting a tiny tube, or stent, into the artery to hold it open. Procedures typically cost around $15,000 to $20,000 and patients usually are in and out of the hospital within 24 hours.

So are insurance companies and government agencies that want to keep health care costs down pushing less invasive surgery?

Not so, say doctors at Pepin. "Medicare doesn't make a judgement on what's the right thing," Bloom said.

Plus, in patients like Arroyo who wind up needing surgery, doing the stents didn't save any money.

While national figures show that angioplasty and stent procedures outnumber bypasses by about 3 to 1, the ratio at some hospitals is even greater.

At Pepin, it's about 6 to 1, with 1,200 angioplasty/stent procedures performed each year, compared with about 200 bypasses, reported hospital spokesman Will Darnall. And the hospital is staffed accordingly: Pepin has about five heart surgeons, compared with 30 interventional cardiologists, who perform stents and angioplasties.

Elchahal said he "will advise surgery only if the angioplasty is not an option."

But some patients don't want to hear they need major surgery.

"We feel ourselves under pressure sometimes," he said. "Sometimes, we have to convince them that, 'no, you need to have surgery because you're not a good candidate (for angioplasty or stents).' "

•••

The three-year SYNTAX trial results suggest that bypass remains the standard of care for patients with moderate to severe disease, defined as blockage in the left main artery, plus blockage in one of the other three heart arteries, or blockage of three heart arteries.

But it also noted that bypass patients were at greater risk of some complications, such as a stroke.

It also found that angioplasty and stents are an acceptable treatment for patients with less-severe disease.

But Elchahal and Bloom say that in practice, things aren't so clear-cut. For example, patients with diabetes, kidney disease, a prior stroke or heart attack, or those who are very old, may not be good candidates for surgery.

The study showed stent patients who had moderate to severe heart disease were 46 percent more likely to need a repeat procedure, 28 percent more likely to suffer from a major event such as a heart attack and 22 percent more likely to die than similar patients who had a bypass.

But Bloom doubts even those statistics will have many people clamoring for surgery.

"It's consumer driven," he said. "You don't really want to have anybody cut your chest open."

Richard Martin can be reached at rmartin@sptimes.com or (727) 893-8330.

Who should have what?

Whether you're better off with a bypass or a less invasive procedure depends on many factors, says interventional cardiologist Dr. Sami Elchahal. Here are some characteristics that would be considered:

Candidates for angioplasty and stenting

• Disease is limited to one or two vessels, or a single area of a vessel.

• Patient is a surgical risk because of kidney or liver disease, diabetes, high blood pressure, prior stroke or advanced age.

• Patient has multivessel disease, but only one of the vessels is severely blocked.

Candidates for bypass surgery

• Patient has moderate to severe coronary artery disease: there is a blockage in the left main artery plus a blockage in one of the other heart arteries; or there are blockages in three heart arteries.

• Blockage is spread through multiple segments of the same blood vessel.

• Location of the blockage is difficult to reach with an angioplasty or stent procedure.

• Patient has had previous unsuccessful stents or angioplasties.

Doctors, patients grapple with best option for coronary artery disease 09/21/10 [Last modified: Tuesday, September 21, 2010 9:39pm]
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