Heart-related chest pain known as angina, and related symptoms like shortness of breath, typically land a person in the cardiologist's office—weighing options that would bring more blood to their heart by propping open vessels or rerouting blood around blockages. But will an angioplasty, insertion of a stent, or bypass surgery add years of life? Will it help prevent a heart attack? Will it improve symptoms in the long run?
Certainly, these sound like reasonable questions to ask before letting a doctor snake instruments through your arteries to widen a vessel narrowed by plaque or to crack open your chest and surgically bypass blockages in your heart. The fundamental fact is that not all heart disease is the same. Yet plenty of patients, referred to a heart specialist trained in one procedure or the other, don't ask questions about how a recommended procedure will impact their type of disease before signing up. "Often, they are speaking to a person who is an advocate for a certain procedure," explains Robert Guyton, chief of cardiothoracic surgery at Emory University Hospital in Atlanta. Practitioners trained to wield specific tools may be biased by what they know—a cardiac surgeon by the scalpel, a cardiac interventionalist by the stent that props open an artery.
In fact, patients may get whisked along to a procedure before there is time to contemplate any of the risks they'll face or benefits they can expect. "Things can happen very, very quickly," says John Wong, general internist and chief of the Division of Clinical Decision Making at Tufts Medical Center in Boston. A treadmill stress test that reveals some dysfunction prompts the cardiologist to schedule an angiogram, which involves injecting contrast dye so blockages show up. The catch is that, because angioplasty can be performed at the same time as the angiogram, patients are often asked if they'd like it all taken care of in one tidy procedure. Clinicians can have an economic incentive from payers to do both at the same time.
A better approach to an elective heart procedure: Build in time to get more than one opinion and consider the risks and benefits of every possible option—including medication, changes to diet and exercise, and the possibility of watchful waiting before committing to a procedure.
Indeed, in many cases, the best first move might be a serious commitment to lifestyle reform and getting on the right medications to control risk factors like high blood pressure. Heart procedures don't necessarily improve survival rates or the likelihood of preventing a heart attack, and a landmark 2007 study in the New England Journal of Medicine found that patients with earlier stages of heart disease didn't live any longer or have any fewer heart attacks after getting angioplasty or a stent than patients who had optimal medical management. Patients with the most severe and complex disease tend to reap the biggest benefit from bypass surgery.
Geography, too, can influence the type of heart procedure a patient gets. Researchers at the Dartmouth Institute for Health Policy and Clinical Practice have long observed very different practice patterns across the United States, not only for heart procedures but for everything from hip replacements to intensive care usage. The most recent information from the Dartmouth Atlas database (based on 2005 Medicare data) shows that for every bypass performed in the United States, there are about 2.6 angioplasty or stent procedures performed. Take a closer look at communities, and the ratio can widen considerably. In Davenport, Iowa, nearly 14 angioplasty or stent procedures are performed for every heart bypass surgery. Toward the other end of the spectrum, in Dover, N.H., and Hopkinsville, Ky., patients have about the same likelihood of getting either procedure. And in Santa Maria, Calif., Owensboro, Ky., and Fayetteville, N.C., heart patients are slightly more likely to get bypass surgery.
The data don't reveal what the "correct" rate of these heart procedures should be, says Elliot Fisher, the Dartmouth Atlas's principal investigator and a professor at Dartmouth Medical School. And with certain exceptions, there isn't a single, agreed-upon treatment option for people with coronary artery disease. "In many cases, there is a choice to be made," says Wong. But patients are rarely presented with every potential treatment option and the comparative short- and long-term risks and benefits—and specifically how that would affect someone like them, who, say, has diabetes, or who is relatively young and needs to do physical labor at their job.