Do You Really Need Bypass Surgery?

What to consider if it's not an emergency and your coronary artery disease is stable.

From the WebMD Archives

It's the news you don't want to hear from your cardiologist: One or more of your coronary arteries -- the blood vessels that supply blood to your heart -- is blocked. You have coronary artery disease, the No. 1 killer of U.S. adults.

So does this mean you're headed for bypass surgery? Maybe not, if your situation isn't an emergency.

You might have other options -- including less drastic procedures to reopen those arteries, medication alone, or even radical lifestyle change.

What's your best option? What risks and benefits would you face from the options available to you?

People with coronary artery disease should know what to ask their doctors in order to decide which treatment is best for them. They should also know that if their heart disease is stable, they may have more time than they think to make the decision.

Phone's Ringing

Cullen Morris, MD, is talking to WebMD about those options when he gets an urgent call. A woman whose coronary artery is blocked in a place that’s too difficult to stent is being rushed to bypass surgery.

“She’s not doing well. We have to get blood flow to the heart quickly,” says Morris, a cardiothoracic surgeon and assistant professor at Emory School of Medicine.

But that's not always the case.

“If your chest pain is stable and you have no new symptoms, we don’t have to drop everything and do bypass surgery like I’m doing for this woman,” Morris says. “But you must be followed closely by your doctor.”

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Coronary Artery Disease

Coronary artery disease (CAD) happens when plaque builds up in the coronary arteries, hampering blood flow to the heart muscle. The most common symptom is chest pain (angina), which can be severe, although some people are more bothered by breathlessness or even unusual fatigue.

Coronary artery disease predisposes people to develop a heart attack and is also the most common cause of heart failure, in which the heart has trouble pumping enough blood to the body.

CAD can block one or more coronary arteries. The plaque may be limited to a small segment of the artery or may be more widespread.

There are several effective treatments for CAD, which can reduce chest pain, make a heart attack less likely, and may prolong life. Generally, the most severe cases warrant the most aggressive treatment, which can also carry the highest risks.

Whether one of these treatments is better than another has long been debated by experts. Here is what each option involves.

Bypass Surgery

In bypass surgery, surgeons take a blood vessel from your leg, arm, or chest and create an alternate route around the blockage or blockages. This is similar to creating a traffic detour around a bad stretch of road.

“If you do bypass surgery, you’re redirecting the blood vessel [flow] around the blockage,” says cardiologist Jonathan Murrow, MD, and assistant professor at Medical College of Georgia-University of Georgia Medical Partnership.

Bypass surgery is most often recommended for patients with blockages in multiple blood vessels or for patients with a blockage in their heart's left main coronary artery, which supplies most of the blood flow to the heart's lower left chamber, the left ventricle.

Angioplasty and Stents

In this procedure, doctors guide a tube through an artery in your arm or groin to reach your blocked coronary artery. When the tube, which is very long but only slightly wider than a pencil lead, reaches the artery, a tiny balloon at the end is inflated to reopen the blood vessel. This is similar to fixing the worst part of a deteriorated road to help alleviate traffic jams.

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“For people with single-vessel disease [CAD in only one coronary artery], many times the preferred treatment is angioplasty,” Murrow says.

During angioplasty, doctors may also insert stents -- mesh tubes that hold the arteries open. Some stents, called drug-eluting stents, slowly release medications that help to prevent the artery from narrowing again.

With angioplasty, you're not getting your chest cracked open for heart surgery. That means a shorter recovery time.

But “when you put a stent in an artery, you’re only treating that 1-2 centimeter segment. The rest could be developing plaque,” Murrow tells WebMD.

Medical Therapy

If you don’t have very severe CAD, treating it with medicines alone may be an option. These drugs may include aspirin to prevent blood clots; beta blockers to reduce the workload on the heart; ranolazine and nitroglyerine for chest pain; ACE inhibitors for heart failure; and statins for cholesterol.

A 2007 study of 2,287 patients, known as the COURAGE trial, showed no difference in death or heart attack rates among stable CAD patients treated with medicine alone vs. those treated with angioplasty. Angioplasty, however, was shown to be a more effective treatment of chest pain.

Lifestyle Changes

A tobacco-free lifestyle that includes exercise, a diet low in saturated fat and salt, and limited alcohol has long been encouraged to prevent heart disease. However, some studies show that comprehensive lifestyle modifications can not only prevent the disease but also treat it.

Studies led by Dean Ornish, MD, who is the founder of the nonprofit Preventive Medicine Research Institute and professor of medicine at the University of California, San Francisco, have continually shown the impact of major lifestyle changes on CAD.

Ornish’s lifestyle plan, which includes a low-fat, whole foods, vegetarian diet; aerobic exercise; stress management; smoking cessation; and group therapy, has significantly reversed CAD in study participants, helped them avoid bypass and angioplasty, decreased heart attack rates, and improved risk factors and quality of life. Medicare recently approved Ornish’s hospital-run programs as a reimbursable treatment for CAD.

“The problem is most people are told to make moderate changes in the diet, and when it doesn’t do much, they’re told ‘We have to operate.’ But if they’re willing to make bigger changes, most people can avoid surgery and they don’t even know that’s an option,” Ornish tells WebMD.

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Bypass or Angioplasty?

When you get down to considering bypass surgery vs. angioplasty, there is no one-size-fits-all solution.

“It’s not a yes or no answer. It’s rare that if a patient doesn’t have a bypass, they are facing a certain adverse outcome. There is a group of patients for whom, on average, surgery lowers risk, but the decision is always personal,” says Harlan Krumholz, MD, who is a cardiologist and professor of medicine at Yale School of Medicine.

It comes down to the details of your particular case -- what's your overall health and medical history, and how severe is your heart disease? If you've had a heart attack before, or have diabetes or severe CAD, that may make you more suitable for bypass surgery than another procedure.

If a patient has a choice between bypass surgery and a less-invasive procedure, he and his doctor must consider that patient’s individual risk for complications and likelihood of benefit. Risks of bypass surgery depend on a patient’s health before surgery and may include bleeding and arrhythmia, and less commonly heart attack, kidney failure, infection, memory loss, and stroke.

“In general, bypass surgery results in more long-term benefit in terms of symptoms, function, quality of life and even survival compared to angioplasty, but you have to take a slightly greater up-front risk of a complication and you have to recover. People recover very quickly from angioplasty,” says John Spertus, MD, who is a cardiologist and clinical director of outcomes research at Mid America Heart Institute of Saint Luke’s Hospital.

Some major studies have shown no significant difference for some patients between bypass and stents or angioplasty in terms of death and heart attack rates. The results of bypass surgery are generally longer-lasting. Patients who undergo angioplasty or have stents placed more frequently undergo additional procedures than do patients who have bypass surgery.

What Should I Do Next?

Because stable CAD does not necessitate emergency surgery, patients followed closely by a doctor might try less invasive approaches first, if they wish.

For some people, that might be a hard choice. Doctors and patients can feel that unless you try the most aggressive surgical approach, you’re not doing everything you can, Spertus says. “And I think that’s human nature, but it’s not really evidence-based.”

“[Patients should] do everything they can to optimize their medical control, to minimize their smoking and other risk factors, to get more active, and see what that does to symptoms and quality of life. If it works, great, and if it doesn’t, go to bypass or angioplasty,” Spertus says.

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7 Questions to Ask

Here are some questions you may want to ask before deciding on a procedure:

  1. “Am I already on the best medication possible?” says Eric Velasquez, MD, whose recent study in the New England Journal of Medicine compared the benefits of bypass plus optimum medications to medications alone.
  2. “What are my personal chances of being better off in the long run? How am I likely to be doing a year from now in terms of survival and quality of life?” Spertus says.
  3. “What are my personal chances of short- and long-term complications with this procedure?” Murrow says.
  4. “How many of these procedures have you done?” Krumholz says. He stresses the importance of patients knowing their doctors’ and hospitals’ success rates.
  5. “What will my recovery time be in the hospital and after?” Murrow asks.
  6. “Are there great-enough lifestyle changes to obviate the need for treatment at all?” Spertus says.
  7. “Will there be long-term limitations on what I can do?” Murrow says.

“For patients with CAD,” Morris tells WebMD, “it is a team approach with you and your doctors.” Being knowledgeable about your heart disease and informed about treatment choices will only make you a better member of the team.

WebMD Feature Reviewed by Elizabeth Klodas, MD, FACC on June 20, 2011

Sources

SOURCES:

Boden, W. New England Journal of Medicine, April 12, 2007.

Koertge, J. American Journal of Cardiology, June 1, 2003.

Ornish, D. American Journal of Cardiology, Nov. 26, 1998.

Ornish, D. Journal of the American Medical Association, Dec. 16, 1998.

Serruys, P. Journal of American College of Cardiology, Aug. 16, 2005.

The Writing Group for the Bypass Angioplasty Revascularization Investigation (BARI) Investigators. Journal of the American Medical Association, March 5, 1997.

Cullen Morris, MD, assistant professor of cardiothoracic surgery, Emory University School of Medicine; medical director, Athens Regional Medical Center, Athens, Ga.

Harlan Krumholz, MD, professor of internal medicine, Yale School of Medicine, New Haven, Conn.

Jonathan Murrow, MD, assistant professor of medicine, Medical College of Georgia-University of Georgia Medical Partnership, Athens, Ga.

John Spertus, MD, clinical director, outcomes research, Mid America Heart Institute of Saint Luke’s Hospital, Kansas City, Mo.

Dean Ornish, MD, Preventive Medicine Research Institute; professor of medicine, University of California, San Francisco.

© 2011 WebMD, LLC. All rights reserved.

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