ANN ARBOR, Mich. - Millions of people with clogged arteries now have a new tool to help them decide, with their doctors, if bypass surgery will help them live longer and better, or if they face too many potential complications and should opt for another approach.
A set of comprehensive guidelines for physicians - based on a review of over 750 studies of coronary artery bypass and its alternatives - is being published in the October issue of the Journal of the American College of Cardiology. It was prepared by a committee of scientists, co-chaired by Kim Eagle, M.D., interim chief, division of cardiology in the University of Michigan Health System.
The report is the first update of the standard-setting American College of Cardiology-American Heart Association guidelines in eight years. It charts the rapid evolution of bypass surgery techniques, and competing medical and surgical techniques like angioplasty.
Most significantly, the guidelines divide heart patients into categories that predict how well bypass will work for them based on their heart condition, age and other factors.
"We used the most current knowledge about bypass to give doctors and patients a way to evaluate all the possible risks and benefits together," says Eagle. "We even address newer procedures, such as minimally invasive bypass, for which we urge caution in the face of uncertainty over success rates and complications."
The guidelines also present the best ways to prevent problems such as infection, heart rhythm problems and stroke, and suggest which medications and lifestyle changes bypass patients need. Finally, the authors call for more research on bypass in older people, minorities and diabetics - patient groups that have been underrepresented in past studies.
Bypass surgery restores blood flow to the heart by transplanting a patient's own veins or arteries to go around one or more blocked arteries. Since its debut in the 1960s, it has been performed millions of times in order to increase survival and reduce symptoms such as chest pain. The Centers for Disease Control says more than 607,000 Americans had bypass surgery in 1997.
The past decade has seen major developments in the form of new diagnostic tools, bypass procedures and methods for preventing or addressing common complications, says Eagle. The result is a marked improvement in post-operative survival, with more than 80 percent of patients still alive 10 years after their operation.
"Enough studies now exist that we can say with confidence that bypass not only increases the length of life, but increases its quality as well," he explains. "For patients with disabling chest pain, bypass can relieve their suffering for 5 to 10 years without posing an unacceptable risk from surgical complications."
Still, he cautions, all bypass patients must face the fact that unless they take their medication, eat right, stop smoking and exercise, they may wind up back on the operating table to have more clogged arteries reopened or bypassed.
"Bypass treats the results of coronary artery disease, not the cause," Eagle says. "It's still discouraging that half the transplanted veins become clogged within 10 years. Bypass patients can and should take the same medications as those who do not opt for surgery."
The guidelines conclude that for certain classes of patients, bypass can be just as effective and cost-effective as other treatments, such as medications to control angina and reduce cholesterol, and angioplasty to remove the blockages in heart arteries. Though angioplasty has historically kept patients in the hospital for fewer days because it is not as invasive as bypass, new "fast track" bypass recuperation approaches have proven effective.
But bypass isn't for everybody, the new guidelines warn. There are many patients with stable coronary artery disease who are best managed with medications and lifestyle interventions.
And despite recent improvements, bypass and other heart surgery does not come without risks. In fact, $1 billion is spent each year to address complications from heart surgery, the guidelines say.
"In the face of this reality, it becomes even more important that physicians have these guidelines to help them and their patients decide which approach is right for them," concludes Eagle. "Only through careful evaluation of risks can we improve patient health while minimizing costs."
Journal
Journal of the American College of Cardiology