ALTERNATIVE OR ALTERNATIVES TO BYPASS SURGERY AND ANGIOPLASTY
Many cardiologists try to convince their patients that opening an occluded
artery with angioplasty, or bypassing it with coronary artery bypass surgery,
will prevent heart attacks or premature death, and that an alternative or
alternatives to bypass surgery such as medical treatment with drugs is not an
option and will not work. Such decisions against an alternative or alternatives
to bypass surgery are usually based solely upon the results of an angiogram
that show the presence of coronary artery disease. Unfortunately, no prior
angiogram is usually available to determine whether the patient's coronary
artery disease is new or old. Without a prior angiogram to compare with, it is
impossible to determine whether the patient's coronary artery disease has
recently progressed. In other words, any coronary artery disease found has
often existed in unchanged form for years. It is, therefore, coincidental, and
there is another reason for the patient's chest pain. If so, then it is even
more likely there is an alternative or alternatives to angioplasty or bypass
surgery. This is particularly likely to be true in patients with recent onset
of chest pain.
Only a few studies have shown a survival benefit with surgery, and these were
done in the seventies before the availability of modern medication. Even these
few studies are suspect as to their reliability because we now know that many
reasons exist for the relief of the patient's chest pain after surgery that
have nothing to do with the bypass surgery itself. For example, placebo surgery
will provide pain relief. In addition, there are no modern studies supporting
the claim that angioplasty and bypass surgery are of clinical benefit, and that
surgery prevents future heart attacks or death compared to bypass surgery
alternatives.
Although symptoms may be relieved in many patients following one of these
procedures, such relief is often only temporary, returning within a few months
to a few years. Furthermore, from our personal experience over the past 23
years at the Noninvasive Heart Center in dealing with many hundreds of patients
with chest pain who have been urged to undergo bypass surgery, most are grossly
undertreated with alternative modern medications and other bypass surgery
alternatives such as exercise, weight loss, cessation of smoking and stress and
blood pressure control. Typically such patients are threatened with medical
terrorism tactics such as "You can have a massive heart attack and die at
anytime unless you undergo immediate surgery!" Such tactics might be
appropriate if they were true, but in the experience of the Noninvasive Heart
Center, not once has any patient ever had a heart attack or died because he or
she were treated with an alternative or alternatives to bypass surgery. It
almost seems that there is a deliberate attempt on the part of the patient's
doctor to undertreat because if such patients were treated properly, their
symptoms would disappear and the patient would reject surgery.
The efficacy of surgery and angioplasty is not only greatly overrated, but the
results of both are unpredictable. Mortality and frequency of complications are
much greater than what the patient is led to believe, and many patients are
worse off after surgery.
The truth of the matter is that the most recent studies, involving now more
than 41,000 patients, and population studies involving more than two million
people (see section on comparison studies) have shown that an alternative or
alternatives to bypass surgery is associated with a far lower morbidity and
mortality. In other words, alternative treatment with modern pharmaceutical
agents as well as other alternatives are highly effective, provided the
cardiologist you are dealing with knows how to use medication. Sad to say, most
do not and prescribe an inadequate number of drugs or too low a dosage. Many
cardiologists are still quoting from studies in the late 1970s which showed
that bypass surgery provided some protection in patients with poor cardiac
function compared to only one bypass surgery alternative treatment with drugs.
Obviously, the medical treatment of the 1970s is hardly appropriate compared to
that of the early 21st century. Today, there are many available drugs, and a
lot more coming down the pike, that make the treatment of obstructive coronary
artery disease very safe, and highly effective. When medications are used in
appropriate numbers and dosages, the patient is able to live a normal life with
a risk of dying or having a heart attack only minimally greater than
individuals without coronary artery disease. This is not only my experience,
but the experience of other noninvasive cardiologists who do not rush every
patient with chest pain in for angiograms and some form of intervention. It
also should be pointed out that not only do angioplasty and bypass surgery NOT
slow down the progression of the disease and its consequences, but actually
accelerate its progression.
Finally, many cardiologist and surgeons will casually dismiss an alternative or
alternatives to bypass surgery with modern drugs and other management
techniques because these alternatives are unable to eliminate or unclog the
obstructed coronary artery. That is true. It is not possible to restore the
obstructed coronary artery back to normal by any form of treatment. But we
don't have to. What modern drug treatment does is to restore blood flow to the
heart muscle in that part of the heart where blood flow is reduced. This is
accomplished by dilating other blood vessels in the same area that are not
blocked. At the same time other drugs reduce the workload of the heart so that
the heart muscle requires less blood. This is like finding another source of
income and reducing expenses if you lose your job. Once income to the heart
muscle (blood flow) is adequate for the expenses (work load) of the heart,
chest pains will disappear, and so will the risk of a heart attack or death..
At this point the body's natural adaptive responses take over with the
formation of new blood vessels through angiogenesis (angio = blood vessels,
genesis = birth of). The result is the formation of a vast network of small
vessels that develop around the obstructed artery allowing blood to flow around
the obstructed artery without resistance. In other words, the heart has put in
its own bypasses with the help of medical therapy with modern drugs that is an
alternative to bypass surgery. Unfortunately, such collateral vessels, as they
are called, are not visible on an angiogram because they are too small to be
seen by this primitive imaging technique. However, other imaging studies such
as an echocardiogram or nuclear imaging will clearly show the heart muscle is
functioning and contracting in a perfectly normal manner, even though the
artery going to that area of the heart is partially or completely obstructed.
How can that be? Obviously, blood is getting through to that heart muscle, even
though this can't be seen on the angiogram---an imaging procedures that has
been around since 1958 and has obvious limitations. Finally, modern drug
therapy is more than just an alternative to bypass surgery and angioplasty. We
now recognize that certain drugs such as beta blockers and Ace inhibitors
actually slow down and even stop the progression of coronary artery disease,
and may even reverse some of the changes that have occurred. Neither bypass
surgery nor angioplasty are capable of doing this.
In summary, an alternative or alternatives to bypass surgery or angioplasty
with modern drugs and other management techniques has changed the natural
history of coronary artery disease. Like so many other diseases of the past
that were lethal and are now considered benign because we have effective
treatment, it is time to downgrade coronary artery disease from the lethal
disease it once was, to a relatively benign disorder which, like arthritis,
might bother you once in a while, but should not shorten your life or
significantly change its quality.
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