June 12, 2000 -- What could be worse than being told you need heart bypass surgery? Being turned down for the procedure because you're too old.
While some surgeons weigh age more than others, conventional wisdom has been that patients over 80 don't fare as well as younger candidates when undergoing cardiac bypass surgery. Now, however, a new study may help to change that thinking and eventually persuade more doctors that age alone shouldn't be a criterion used to deny a heart patient a bypass operation.
The Key Is Selection
Duke University Medical Center cardiologist Karen Alexander, MD, an assistant professor of medicine, analyzed data from 67,764 patients, including 4,743 octogenarians, and found that carefully selected patients over 80 can weather bypass surgery nearly as well as younger folks.
Octogenarians face added risk when bypass is combined with replacement of the heart's mitral valve, according to the paper published in the March 1, 2000 issue of the Journal of the American College of Cardiology. But the author says patients who have no other risk factors -- such as prior heart surgery or serious stroke -- should be able to withstand bypass surgery and return to a normal life.
The healthiest 80-plus patients in the study who did not have a history of congestive heart failure, lung disease, or vascular disease and who did not need the bypass on an emergency basis did best among the octogenarians.
Overall, 8.1% of octogenarians died in the hospital after bypass surgery compared to 3% of younger patients in the study. But when the healthiest of the elderly patients without the other risk factors were looked at, the rate was 4.2% -- not that much higher than for younger patients undergoing bypass.
In the bypass procedure, veins are removed from the leg or arteries are taken from the mammary arteries in the chest region. These grafts are connected above and below the blockage in the coronary artery (or arteries), bypassing it and restoring good blood flow.
If patients are well selected, even older ones can do well, the study shows.
An Octogenarian Success Story
Case in point: 89-year-old Albert Carlsen, a retired engineer who divides his time between homes in Idaho and Rancho Mirage, Calif. Carlsen underwent a double bypass operation in November at The Heart Hospital of the Desert in Rancho Mirage and has since resumed walking, gardening, and golfing.
"There's obviously some risk when you get up where I am," says the strapping, square-jawed Carlsen. "But heckfire, I went through that operation with flying colors. I was up in three days, dressed, and ready to go home."
A Bypass Believer
Such success stories are the norm for Carlsen's surgeon, Jack Sternlieb, MD, president and founder of The Heart Hospital. "I feel confident in operating on these people," says Sternlieb, who practices in a retirement mecca with a large elderly population. "This operation shouldn't kill you. That's the point."
The average age of his patients who come in for bypass, he says, is 74. Despite the potential risk, Sternlieb says chronological age alone should not be a deciding factor. "Age is not a criterion." (In keeping with his policy, the boyish-looking doctor doesn't reveal his own).
Instead of focusing on age, Sternlieb looks at psychological and social factors: "Does the patient really want to live? Do they have a good appetite? Do they have a support system? At this age, you can't just operate on them and abandon them," he says.
Getting Good Outcomes
Sternlieb is unimpressed with mortality rates reported in the Duke study, saying the numbers are still too high. "If I had mortality rates that high, I'd quit," he says. "It's possible to do this procedure much more safely."
In a recent study by Healthgrades.com, an independent online rating service, Sternlieb's hospital had the lowest in-hospital heart surgery mortality rate in the country, based on 1998 Medicare data. (In-hospital mortality rates include the number of patients who died after the surgery while still in the hospital.) While Alexander of Duke University cites a nearly 20% in-hospital mortality for elderly patients who had combined bypass and valve surgery, Sternlieb's rating for both bypass as well as the combined procedure was zero deaths -- the only cardiac program in the country to make such a claim.
Mortality data is gathered by the Health Care Financing Administration, which administers Medicare. Various organizations then analyze and distribute the findings.
The low mortality rates at The Heart Hospital, Sternlieb says, are not just due to careful selection of patients but also to the unique design of the facility -- one of the few hospitals in the country devoted solely to heart surgery. The posh 12-bed facility is set up to allow instant life-saving interventions and round-the-clock monitoring. Even when off-duty, Sternlieb keeps an eye on his patients' hearts from remote monitors set up in his nearby home. The doctor sometimes even spends the night in a patient's room. (And, it's generally acknowledged that patients who have had access to lifelong quality medical care have better odds of success, too.)
While he has shown it's possible to perform heart surgeries safely on older patients, Sternlieb cautions that there is still a risk, and that the risk can be unacceptably high in many facilities.
(Consumers can check out a facility in advance. The Healthgrades site, for instance, has an eight-page report on how to select a hospital. The Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org) grades hospitals nationwide.)
The decision to do bypass surgery must always be decided on an individual basis, Sternlieb says. "An 80-year-old doesn't have the reserves of a younger patient and can't afford as many complications," he says. Elderly women, especially, can be at high risk due to their smaller arteries and increased frailty.
Ultimately, Sternlieb says, his older patients may do better emotionally than their younger counterparts. Patients 80 and older spend less time anguishing over the surgery, require less hand-holding, and are not nearly so anxious about mortality, he says.
Albert Carlsen advises others his age: "If you need the operation, by golly, have it done. I'm very glad I did."
Alexander, the study author, sees his point. "As we're getting more experience and more knowledge about outcomes in this age group, we're finding there's no reason to exclude people offhand because of age."
Ann Japenga is a contributing editor to Health magazine and a former Los Angeles Times reporter. She lives in Palm Springs, Calif.