Bypass Surgery: Harder Operation, Safer Option

New Study Says Bypass Surgery Is Better Than Angioplasty For Heart Patients With Diabetes. Surgery or stent? Bucking the popular trend, a comprehensive study shows surgery is better, particularly for diabetics suffering from advanced coronary heart disease (CHD). Such patients are more likely to live longer, healthier lives after a heart bypass than after an angioplasty. The finding is particularly significant for India, the diabetes capital of the world, where one-third of all heart patients are diabetic. 
    
The study was published in the New England Journal of Medicine (NEJM) following a trial funded by the National Heart, Lung and Blood Institute, a division of the National Institutes of Health in the US. The trial, one of the largest till now on the subject, involved 1900 patients with diabetes, all in their early sixties. While half of them had bypass surgery — medically known as coronary artery bypass grafting (CABG) — the rest underwent multivessel angioplasty with drugeluting stents (also known as percutaneous coronary intervention or PCI). These patients were followed up for five years. 
    

The study concluded that for diabetic patients with advanced (predominantly three-vessel) CHD, bypass surgery was superior as it significantly reduced rates of death (10.9% vs 16.9%) and heart attack (6% vs 13.9%). However, of those undergoing a bypass, 5.2% suffered a stroke compared to 2.4% of those who underwent an angioplasty. 

“These results are consistent with the findings of multiple previous trials comparing CABG and PCI in 
patients with diabetes,” stated an NEJM editorial on the subject. Prof Balram Bhargava of the cardiology department at AIIMS was one of the authors of the study. He says the trial, involving such a large number of patients and such a long follow-up, finally lays the debate — open heart versus stenting — to rest, at least for diabetic patients with advanced CHD. “Open-heart surgery is not as daunting an option as it used to be and has evolved greatly over the years. In AIIMS, we have 11 operation theatres where we do three open hearts per theatre or 33 surgeries every day. It is a robust alternative,” he says. 
    
An angioplasty specialist himself, Dr Bhargava points out that the study shows the importance of “team approach” in diagnosing and treating coronary disease rather than just the cardiologist deciding which patient he would send for surgery and which one he would do stenting on. It has to be a combined decision of the cardiologist and the cardiac surgeon, particularly in the case of diabetics, he adds. 
    

There have been major advances in stenting procedures. Yet, studies have consistently shown a trend towards more frequent “major adverse cardiovascular and cerebrovascular events” in diabetics who underwent stenting. In spite of this, the procedure is becoming increasingly the more preferred option, observed the editorial. 
    
Why is this so? “Many PCIs today are ad hoc procedures, performed at the time of diagnostic coronary angiography, with the same physician making the diagnosis, recommending the treatment and performing the procedure. There is little time for informed discussion about alternative treatment options, either medical therapy on the one hand or CABG on the other,” stated the editorial, adding that diabetic patients ought to be informed about the potential survival benefits of open-heart surgery for treatment of severe heart disease. 
    
Ideally, the discussion ought to start before the angiography so the patient has time to digest the information, discuss with family members and also with a multidisciplinary heart team before making an informed decision, advised the NEJM editorial. 
    
“The patient should not be taken in for an ad hoc angioplasty. At the time, he/she is under too much pressure to make an informed decision. It has to be a more elective procedure,” explains Dr Bhargava. 
    

But for now, most patients are harried and hurried by their doctors into getting one or more stents soon after an angiography. The profit margins may leave little scope for discussion. 

MATTERS OF HEART 

• LETHAL MIX - 61.3 million people over 20 are diabetic in India More than one-third of India’s heart patients are diabetic 
• TAKING THE BYPASS - First performed in India in 1975 In mid-1990s, 10,000 surgeries annually; now 1 lakh per year 
• BALLOONING OPTION - In 2011, 1.2 lakh angioplasties performed; 2 lakh stents placed Stent market growing at 22-25% per year in India Docs say chances of blockage recurrence higher in angioplasty than after bypass. In diabetics, chances 3 times higher Surgery considered better in cases where all three major arteries are involved