The Heart Beat

Over on the Heart Disease Support Board at Web MD, “Vlad” reports that his dad recently suffered a heart attack, and that there is now controversy in his household about whether or not his father should undergo the recommended coronary artery bypass and mitral valve replacement surgery; his dad has 3-vessel disease and a leaky mitral valve.

Vlad shares that his dad is frightened at the prospect of having surgery, and his mom, who has read a book called “Heart Frauds” by obstetrician-gynecologist Dr. Charles McGee, thinks that there is no benefit to his having the surgery. According to Vlad’s post, the premise of McGee’s book is that there has never been any actual proof that CABG surgeries extend a person’s life. Vlad writes that he is “terrified of pressuring my dad into a potentially life-threatening surgery if he could survive without it” but on the other hand, he’s also afraid that his dad will have another heart attack if he doesn’t have the surgery.

Vlad asks an interesting question, especially to those of us in medicine who have become accustomed our patients being referred to have bypass surgery. First of all, in this day of evidenced-based medicine, I really doubt the surgeons would continue to perform a procedure that had no merit whatsoever. Second of all, cardiovascular disease has been proven to be progressive; if a person chooses not to have surgery, they will eventually have the opportunity to make that choice again, although no one can predict how soon that will happen. According to the American Heart Association, in an analysis of seven studies of individuals who had chosen medical management rather than open-heart surgery, a range of 37-50% in had crossed over to have bypass surgery in the 10-year follow-up period.

There are a number of factors that effect surgical outcomes and life expectancy post-bypass, and for those who are interested in the details I recommend that they read the ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: Executive Summary and Recommendations, published in 1999 in the journal Circulation. One of the interesting points made by this article is that their analysis is being made on studies from the 70-80′s. These studies were completed before the current trends in medical management of heart disease were known, such as the consistent use of drugs like beta-blockers, ACE-inhibitors, and lipid-lowering agents.

Since I haven’t read Mr. McGee’s book, it may be that his premise is exactly this: we don’t know what changes in medical management will do to the surgical versus medical management arguments. But the surgeons get to argue on the flip side: bypass surgery is being made safer by procedures that allow them to open the chest only minimally or to work on a beating heart, and moving to the consistent use of the internal mammary artery for grafts has increased graft success rates. These procedures, like the newer medical management techniques, have not yet been put through the same comparative analysis. My guess is that analysis is underway now, knowing something about how the American Heart Association (AHA) works.

Where does all this leave Vlad’s dad? Well, there are certain things that we are still sure about when considering an individual for open-heart surgery. There are health conditions that can affect a person’s surgical outcomes; these include:

• Age: patients over 70 are at a slightly higher risk for complications.
• Gender: women have a slightly higher risk.
• Previous heart surgery puts a person at a higher risk.
• Having another serious medical condition: diabetes, peripheral vascular disease, kidney disease, or lung disease.

There are also possible risks in having coronary artery bypass grafting (CABG), which include:

• Heart attack, which occurs in 5% of these surgeries.
• Stroke, which occurs in 5% of these surgeries (the risk is greatest in those over 70).
• Blood clots.
• Death, which occurs in 1-2% of those who have the surgery. That also means that 95-98% have no serious complications.
• - Sternal wound infection, which occurs in 1-4% of these surgeries (this complication is most often associated with obesity, diabetes, or having had previous CABG).

Addressing question of long-term survival, the AHA reports on a collaborative (with the American College of Cardiology) meta-analysis of 7 trials with a total enrollment of 2649 patients, which has allowed comparison of surgical versus medical outcomes at 5 and 10 years. Among all these patients, the extension survival of CABG surgical patients compared with medically treated patients was 4.3 months at 10 years of follow-up. That doesn’t seem to be much, but it’s in the breakdown of the subgroups where the differences really show. For example, in patients who had a diseased left main coronary artery, the median survival for surgically treated patients was 13.3 years versus 6.6 years in medically treated patients.

Based on Vlad’s description of “three-vessel disease,” it is likely that his dad left main artery is involved in his disease process. According to this report, “the benefit of surgery for left main coronary artery disease patients continued well beyond 10 years. By 15 years, it was estimated that two thirds of patients originally assigned to medical therapy and who survived would have had surgery. The 15-year cumulative survival for left main coronary artery disease patients having CABG surgery was 44% versus 31% for medical patients.” Additionally at 5 years two thirds (66.6%) of the bypass patients had no symptoms, compared with 38% of the medically managed patients. At 10 years symptoms were about the same and the authors attributed this to the use of vein grafts in the bypass patients as well as the crossover of medical patients to having bypass surgery. Again, this outcome points out things that will be evaluated in the future analysis of studies from the period between the late 80′s and the early years of 2000, when use of the internal mammary artery had become the norm in bypass grafting.

Paul Prudhomme, chef-owner of the famous K-Paul’s Restaurant in New Orleans and heart patient, tells a story about how he came to write the book “Chef Paul Prudhomme’s Fork in the Road: A Different Direction in Cooking.” Having developed heart disease, Chef Paul decided to turn to healthier cooking, and to produce a book for individuals with health concerns. He talks about how he came to his own “Fork in the Road,” where he had to make healthier food choices. I have been told that he notes in this story that we all make the best possible choices with the best available information given to us at the time that our choices are made.

Eventually we each will reach a personal fork in the road. We’ll take the best information available to use, combined with the recommendations of the professionals that we are paying to advise us, and if we trust them, we will feel comforted that we have made the best possible decision for that moment. Vlad’s father is being advised to have bypass su
rgery and a repair of his mitral valve. I think if I were in his shoes, I’d have the surgery.

Laurie

Convinced myself, I seek not to convince.
Edgar Allan Poe (1809 – 1849), Berenice

Related Topics: Repair or Replace Mitral Valve?, Nonsurgical Treatments for Heart Disease