WEDNESDAY, Dec. 29, 2004 (HealthDayNews) -- A new study finds that for most people undergoing elective vascular surgery on the lower legs or aorta, fixing the heart first with a bypass or other procedure yields no better results than using drugs.
These findings, reported in the Dec. 30 issue of the New England Journal of Medicine, led the authors to conclude that bypass and related procedures should not be used among people with stable cardiac symptoms.
"There's no survival benefit of an up-front strategy of fixing the heart," said study author Dr. Edward O. McFalls, director of cardiac research at the VA Medical Center in Minneapolis. "Medical therapy has evolved in the past 30 years and may be protective, and it may be a better therapy because it prevents the [elective] surgery from being delayed."
"What we're learning more and more is that we need to treat patients who have vascular disease with aggressive preventive and medical therapy, and that's lifestyle and great medicines. Those are the treatments that probably have the most profound impact on trying to help reduce sudden catastrophic events like strokes and heart attacks," added Dr. Kim Eagle, co-author of an accompanying editorial and clinical director of the University of Michigan Cardiovascular Center in Ann Arbor. "Interestingly, we're using our interventional therapies when the symptoms justify it . . . so, in a way, the two types of strategies have to be complementary."
People with blocked arteries are at the highest risk for complications when undergoing surgery. The question has been how to best prepare these individuals for surgery: to treat them before the surgery with a bypass procedure or a balloon angioplasty or to avoid an extra procedure and stick with medication. Thus far, there has been no consensus among experts on the issue.
"Since we know that surgery is stressful on the heart, if a patient has significant coronary artery blockages, how do we best deal with that if they have to go through a stressful vascular operation," Eagle said.
"It's either fixing the heart before the major operation or providing just medical therapy," McFalls added.
Elective vascular surgery does not have to take place immediately, giving the cardiologist options to take other measures to repair the heart, McFalls explained. While not urgent, it is deemed necessary for patients to improve both their long-term survival odds and their quality of life.
This study involved 510 men with stable coronary artery disease who were at an increased risk for cardiac complications related to surgery. While waiting for elective major vascular surgery on their aortas or lower legs, all participants were randomly assigned to undergo either revascularization or no revascularization.
Revascularization meant either percutaneous coronary intervention (opening up one of the blood vessels leading to the heart to restore blood flow) or coronary artery bypass grafting (inserting a detour around the blockage). No revascularization participants were treated with drugs such as statins and beta blockers.
One-third of the participants needed an operation to bypass a blockage in the aorta, while the other two-thirds needed a bypass of the lower extremities because of pain, McFalls said.
Individuals in the revascularization group ended up waiting about 54 days until surgery, three times longer than those in the no-revascularization group.
After 2.7 years, the death rate among both groups was essentially similar: 22 percent in the revascularization group and 23 percent in the other group. In addition, within 30 days of the vascular operation, 12 percent in the revascularization group and 14 percent in the no-revascularization group had had heart attacks.
"The benefit to that type of approach was not any greater than using really excellent medical therapy to try to protect the heart during and after surgery," Eagle said.
McFalls felt that the findings were likely to have an immediate impact on clinical practice.
Eagle, however, felt there was a danger in over-generalizing the results. "They studied a very select group of patients which had been carefully screened beforehand," he pointed out. The participants in the study did not have unstable symptoms, had not suffered recent heart attacks, and did not have a blockage in the left main coronary artery, where bypass is generally recommended.
"Extending those conclusions to anybody and saying this shows you don't have to worry about coronary artery disease, just treat them with medicines, that would be a mistake," Eagle said.
The National Heart, Lung, and Blood Institute has more on coronary artery disease.