I see from a recent study published in Circulation that about half of the patients who would be better off having heart bypass surgery wind up getting a stent instead. Can I keep that from happening to me?
The decision regarding who should receive a stent and who should receive bypass surgery is complex and must be individualized for each patient. There are some general principles, though. For patients having a heart attack or otherwise unstable chest pain, urgent heart catheterization and stenting have been shown to save lives. For patients with a stable chest pain syndrome (pain only with exertion), both stenting and bypass surgery have been shown to reduce symptoms. If catheterization shows only one or two readily treatable blockages, stenting may make good sense because it relieves the symptoms without the need for open heart surgery. If there are more than a couple blockages, however, most experts believe that bypass surgery is preferable, particularly if the surgeon uses the internal mammary artery to perform one or more bypasses. Internal mammary bypasses have more durability in the years following surgery than bypasses using the veins harvested from the legs.
Keep in mind that stenting in patients with stable chest pain has not been shown to prolong life or prevent heart attacks, so stenting should be used primarily to relieve symptoms that interfere with a patient's quality of life. You should also know that medical therapy using drugs can improve symptoms in many patients and remains a viable option. Bypass surgery has been shown to prolong life, particularly in patients with severe blockages in whom damage from a heart attack has weakened the heart muscle. Also, there is some evidence that surgery is better than stenting in patients with diabetes.
How can you decide which option is best? If you are not certain, seek a second opinion, preferably from a cardiologist who is not a procedural specialist. If you consult someone who actually does the procedure, you should remember Mark Twain's adage, "to a man with a hammer, everything looks like a nail."
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