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.
Considerable differences in practice patterns are not lost on the major professional cardiology groups. In an effort to give practitioners some type of baseline for when it is appropriate to do any procedure at all—be it bypass surgery or an angioplasty and stent—six of the major groups put out a consensus document in January that addresses about 180 of the most common types of patient situations based on severity of their angina symptoms. The aim was not to dictate which procedure to use in a given patient or offer treatment guidelines but rather to suggest whether doing a procedure to increase blood flow in the heart would be "appropriate" or "inappropriate" or "uncertain." Gregory Dehmer, one of the document's lead writers and an interventional cardiologist and professor of medicine at Texas A&M College of Medicine, says that, in the future, "I'm going to always ask [myself], 'Would this be appropriate according to the criteria?' and if not, but I feel it needs to be done, I'm going to have to ask myself, 'Why am I doing it?' " Patients should be aware that the document exists, he says, and consider it a starting point for discussions with their doctor.
Heart patients must also know that theirs is not simply a plumbing problem. Neither an angioplasty plus stent insertion nor a bypass procedure is typically recommended unless the artery is at least 50 to 70 percent blocked. Opening smaller blockages with angioplasty or a stent can prompt the vessel to suddenly close up, and undergoing major surgery is not typically advised for early-stage disease. Yet in the vast majority of cases, it's the rupturing of unstable plaque from arteries with less significant blockages—maybe closer to 20 percent—that causes a blood clot that triggers a heart attack. Therefore, using medications to stabilize these dangerous plaques is critical. On the other hand, while the larger blockages don't typically cause a heart attack, they do cause angina, which may be predictable and not very serious but also can be unpredictable and cause crushing pain. Patients are well advised to spend time considering how tolerable their symptoms are, since undergoing either angioplasty or bypass surgery could trigger a heart attack. You should undergo angioplasty, get a stent, or have a bypass, advises Wong, only if you suffer from severe angina even after time on the right medications, an improved diet, and a regular exercise program—and off cigarettes.
Surgery becomes the clear option, says cardiac surgeon Guyton, in very complex disease—large blockages in three vessels, say, or in the critical left main coronary artery—where the heart muscle is compromised by getting considerably decreased blood flow. Results of a study presented at the 2008 European Society of Cardiology Congress found that patients with advanced disease—with multivessel blockages, say—were better off getting bypass surgery than an angioplasty and stent. Twelve percent of patients who had bypass experienced death, heart attack, stroke, or the need for a repeat procedure, compared with nearly 18 percent who had angioplasty or a stent.
However, according to the new appropriateness document, angioplasty and stent placement in a patient with three-vessel disease and diabetes, for example, was deemed neither "appropriate" nor "inappropriate" but "uncertain." Bypass surgery in such a patient is considered "appropriate." Certainly, the less-invasive procedure may be the best option if the person is too frail to withstand major open-heart surgery. On the other hand, if they are unaware of all their options, patients who are sturdy enough to undergo the surgery may run the risk of being swayed in the direction of the less-invasive option, which in the long run might not be as effective.
To be sure, going through bypass surgery is no small feat. A person who gets a stent may be up and mobile in days, but bypass patients can take weeks or months to feel like themselves again. And the surgery also carries a long-term risk of cognitive loss or depression, possibly related to having relied on a machine to pump oxygenated blood to the organs while the heart is stopped during the hours-long surgery. Another trade-off to consider is the likelihood of needing further procedures. With bypass, about 3 out of 100 patients will require another procedure within the first year. Depending on the type of stent a patient gets, somewhere between 9 and 18 out of 100 patients will need another procedure within the first year.
Patients—the ones who actually live with the treatment, its side effects, complications, and any benefits—can and should be participating in the decision making, Fisher says. "We believe in informed patient choice," he explains, "not informed patient consent." The smart way for heart patients to get all the risks and benefits of each option laid out is to make appointments with several different types of doctors: a cardiac interventionalist who would perform the angioplasty and place the stent, a cardiac surgeon who would handle a bypass, and a general internist who does neither procedure and might be more likely to present unbiased information. Without all the comparable risk and benefit information, "patients may think [a procedure] is a cure," says Wong. The reality is, these are not.
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