You are in the hospital after being admitted with a bad episode of chest pain. Your doctors tell you that, fortunately, you do not seem to have had any damage to your heart — but it was close. All the evidence suggests that you have coronary artery disease, and a coronary angiogram confirms the diagnosis. You have narrowings in two of the three major blood vessels supplying the heart.
At first, you hope that medications will solve your problems, but you have another episode of pain while doing practically nothing in the hospital. Your doctors tell you — correctly — that most patients with pain at rest need bypass surgery or angioplasty in order to control their symptoms and reduce their risk for a heart attack. You agree to go with a more aggressive approach.
But which procedure do you have? Bypass surgery, which requires opening up your chest? Or angioplasty, which is performed via thin catheters inserted into a blood vessel in your groin?
If the choice between these two procedures was just based upon its discomfort alone, there is no question that everyone would choose angioplasty — except, perhaps, the most dedicated masochists. People who have bypass surgery usually need at least two months before they can resume their usual activities, and during that recovery period, their chest hurts intensely every time they laugh or cough. People who have angioplasty can often go back to work in a day or so.
But there are plenty of other issues that make the choice much more complex. The first is "durability" — that is, the likelihood that the procedure will "fix" the problem once and for all. On that count, bypass surgery wins hands down. Over the next six months, hardly anyone who has had bypass surgery needs another procedure because of recurrences of chest pain. It is a very different story with angioplasty, because recurrences of the narrowings (restenosis) occur in about one-third of patients. That rate has decreased with the new drug-coated stents that are increasingly common in the U.S. marketplace, but these devices are still so new that no one knows for sure if they prevent restenosis, or just postpone it for a few years.
For people with very severe disease, bypass surgery is often the better choice, since it is more likely to allow restoration of blood supply to all the areas of the heart that are threatened. This may be the reason that several studies have shown that people with diabetes tend to do better with bypass surgery than angioplasty. In addition, there are many patients who have narrowings that just do not lend themselves to angioplasty. For these patients, bypass is the only option.
Whatever advantages bypass surgery may have had in the past, there is a strong sense among many physicians that angioplasty is catching up — and surpassing it as the procedure of choice for more and more patients. First, angioplasty is getting better and better technically, with clever new devices and wire stents that help prop vessels open. Researchers have learned how to use new drugs to prevent blood clots from forming after an angioplasty, causing sudden blockages of the coronary arteries.
In addition, physicians have become increasingly aware of problems with memory and depression after bypass surgery. At least some of these problems are believed due to showers of debris from inside the blood vessels reaching the brain — not an attractive prospect for a patient contemplating this operation. Many hospitals now offer “off-pump” bypass operations, in which the patient does not have to have his or her normal blood circulation stopped. This approach is technically more difficult, but many experts believe it can reduce the risk of neurological problems after bypass. Still, its long-term benefits are far from proven.
Because of the rapid rate of progress in angioplasty technique, the number of angioplasties today is more than double the number of bypass graft operations. That margin may widen in the years ahead. A key factor for any patient offered a choice between the two is the experience of the physicians involved. Regardless of which procedure is chosen, physicians who do the procedure often and have a record of good outcomes are more likely to perform the operation without complications. Don’t be afraid to ask about this issue, or to ask your doctor to help you weigh the concerns about safety and effectiveness described above.
Thomas H. Lee, M.D., is the chief executive officer for Partners Community HealthCare Inc. He is a professor of medicine at Harvard Medical School. He is an internist and cardiologist at Brigham and Women's Hospital. Dr. Lee is the chairman of the Cardiovascular Measurement Assessment Panel of the National Committee for Quality Assurance.