A tale of two bypasses


By John DiTraglia



“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way—in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.” A Tale of Two Cities, Charles Dickens

Two kinds of bypass surgeries are the subject of studies presented at the American Heart Association’s scientific meeting on November 16-18 in Philadelphia.

The first of these procedures is coronary artery bypass graft (CABG). More than 200,000 people have these surgeries done every year. It costs about $45,000 each time. Between one and three percent of patients die before they leave the hospital. Typically, they’ll spend a week in the hospital. Recovery usually takes between six weeks and three months.

This landmark study called “Ischemia,” presented at the AHA meeting, found no advantage in primary outcomes – heart attacks or death – for patients who had CABG or stents compared to medical care alone in patients in who were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery, two situations in which opening arteries with stents can be lifesaving. Instead, the patients had narrowed arteries that were discovered with exercise stress tests. These findings of this large federal study on bypass surgeries and stents call into question the medical care provided to tens of thousands of heart disease patients with blocked coronary arteries, scientists reported. The chair of this landmark study, Judith Hochman, also said “there was no suggestion that any subgroup benefited.” Stenting and bypass procedures, however, did help some patients with intractable chest pain, called angina.

This is far from the first study to suggest that stents and bypass are overused and it won’t be the last. For one thing these trials did not include today’s improved stents, which secrete drugs intended to prevent opened arteries from closing again.

But with 5,179 participants followed for a median of three and a half years, Ischemia is the largest trial to address the effect of opening blocked arteries in non-emergency situations and the first to include today’s powerful drug regimens. All the patients had moderate to severe blockages in coronary arteries. Most had some history of chest pain, although one in three had no chest pain in the month before enrollment in the study. (2) The number of deaths among those who had stents or bypass was 145, compared to 144 among the patients who received medication alone. The number of patients who had heart attacks was 276 in the stent and bypass group, compared with 314 in the medication group, an insignificant difference.

Stenting costs an average of $25,000 per patient in the United States. The nation could save more than $775 million a year by not giving stents to the 31,000 patients who get the devices even though they have no chest pain, Dr. Hochman said.

The other bypass is gastric bypass. Most patients stay in the hospital for only two or three days. Recovery typically takes three to five weeks. It costs an average of $23,000. Deaths occur in less than 0.5 percent of patients in the first 30 days after the operation. This kind of bypass reduces the risk of heart attacks, diabetes, and certain cancers. In addition, the new data presented this weekend demonstrates a lower risk of stroke for people who have this procedure. But only a fraction of those who could benefit – about 41,000 – have this procedure each year. This kind of bypass also improves quality of life.

Why are we doing too many of the heart kind of bypass and not enough of the gastric kind? that would prevent a lot of heart kind.

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By John DiTraglia

1. https://conscienhealth.org/2019/11/a-tale-of-two-bypass-surgeries/

2. https://www.nytimes.com/2019/11/16/health/heart-disease-stents-bypass.html

1. https://conscienhealth.org/2019/11/a-tale-of-two-bypass-surgeries/

2. https://www.nytimes.com/2019/11/16/health/heart-disease-stents-bypass.html