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.