Bypass Surgery and Its “Benefits”
For too many years now, heart disease has remained this nation’s leading cause of death, which begets the question, “What is our health care system doing about it?”
Unfortunately, most of the interventions we have today are merely for symptom control, the primary symptom of which is chest pain or angina. Many patients with heart disease suffer from chest pain (angina) due to a fixed lesion that blocks a majority of the artery (>70%). Lesions that block the heart by 70% or more may cause chest pain with exertion but rarely cause heart attacks. Old, hard, stable lesions are not the ones that rupture and form a clot, blocking the entire vessel (heart attack). Hence, these are NOT the lesions that generally kill people. Rather, it is the newer, softer, smaller (<40%) lesions that are more likely to rupture their contents (similar to a pimple popping) and stimulate sudden clot formation. These clot blockages cut off blood flow to the heart muscle and often lead to sudden death (still the most common symptom of a heart attack).
So, what are we doing about this? Well, the problem is that the screening stress tests we currently use pick up the older, isolated, more stable blockages of 70% or more (i.e. the lesions that are big enough to block enough blood flow during exercise to cause chest pain and EKG changes). And although we can bypass and angioplasty these larger lesions, they are not the ones that kill. On the other hand, stress tests have no ability to detect, the smaller, more lethal lesions that can rupture and stimulate clot formation. These smaller lesions or pimples occur all along the blood vessels, big and small. Unfortunately, doctors cannot angioplasty or bypass diffuse disease like this. So based on this physiology you can understand why we ask the important question: Does bypass prolong life? The answer, as we would expect, is that no prospective study has shown that it does.
The only data currently out there, shows that there is no difference as far as living longer when comparing bypass surgery to just taking medicines. When one study did a subgroup analysis of the data, they found that people with decreased heart strength (low ejection fractions) lived longer with surgery. And note that this was only 2% per year, which means that 98 out of 100 of those people did NOT have any mortality benefit per year. What’s worse, this minimal benefit was only flushed out through subgroup analyses after the study was completed. Which means that this benefit could mean something but could also mean nothing. For example, we could have also done another subgroup analysis afterwards of all the people in the study that drove green cars. Now, if they all happened to live longer in the study if they got surgery, would it behoove us to recommend to all of our patients with green cars to get surgery, telling them that they will live longer with surgery than if they just take medicine? We think not. Ultimately there is no prospective data that supports that people live longer or have fewer heart attacks if they get bypass surgery.
In fact, the only benefit in prospective studies (not subgroup analyses) was symptom control. And this doesn’t last anyway. After 3 years 1/3 of the patients have symptoms return, and after 10 years half of the patients will have died, had another heart attack, or have their chest pain return. But let’s say for a moment that CABG (coronary artery bypass graft) is actually better at symptom control. We have a problem with what they are comparing surgery to in these studies to be able to say that surgery is BETTER at symptom control. It may be better than doing nothing and it may even be better than certain medications; although in these days even medically treated patients do pretty well. Our question is, have they ever compared surgery to TRUE lifestyle modification? Every doctor responds to this question by saying that their patients never listen when they tell them to eat better and lose weight. The problem with that argument is that just telling someone to eat better and lose weight is like telling someone to just build a house even though they were never shown how.
The funny thing is that there is also a large placebo effect with bypass surgery, which is great when it is a sugar pill, but a lot more concerning when it involves something as risky and expensive as surgery. People that underwent “sham” bypass procedures also felt better after the “procedure.” Moreover, patients continue to feel better even after multiple bypass grafts are found to be re-clogged on repeat testing down the road. So if it was the bypass that helped them feel better shouldn’t they develop chest pain again once the grafts fill back in?
Another concern is that the risks of surgery are often underestimated. 1-2 out of 100 people will die from bypass surgery. There is risk of bleeding, infection, heart attack, breathing problems, and stroke during the procedure. Many of the people (about 80%) who get surgery done will have mild cognitive impairments afterwards (due to little strokes that occur after both being on the “heart-lung machine” as well as the vessels getting manipulated during surgery, leading to small pieces of plaque and debris coming off of the walls and going into the brain). After undergoing bypass surgery, almost all patients will have vague but significant cognitive complaints such as, “I’m just not as sharp as I used to be,” or “Now I have these unusual mood swings.” Then there is the pain and rehabilitation issue after such a big procedure that is nonexistent with medical management or lifestyle/diet modification. Even with the “safer” angioplasty if you were able to avoid the small but significant risk of retroperitoneal bleeding (severe bleeding into your abdomen) and dissection (ripping of one of the heart vessels), afterwards you still have the risks/side effects of repeat clogging of the stents as well as medications like blood thinners that are hardly benign.
In the case of bypass surgery doctors can’t say it saves lives but they can say that they THINK it could save lives in a small subgroup of people. That is just not enough when it is such a risky procedure with alternatives (TRUE diet/lifestyle modification) that have not been adequately tried prior. True lifestyle modification would be successful if patients were actually shown how to do it successfully. A study by Dr. Caldwell Esselstyn, from the Cleveland Clinic, had 23 patients (18 remained in the study after two years) who together had suffered from 49 coronary events (angina, bypass surgery, heart attacks, strokes, and angioplasty) in the eight years leading up to the study. He did a study of “extensive” diet modification, eliminating all animal products except skim milk and nonfat yogurt (5 years into the study he eliminated all dairy as well), and watched participants’ average total cholesterol go down from 246 to 132. In the next eleven years there was one coronary event and that was in the one patient that strayed from the diet for 2 years. The patient developed angina, which actually made him return to the study diet. Seventeen years into the study all but one of the patients were alive and they had ZERO coronary events. Not only did Dr. Esselstyn stop the progression of heart disease, he reversed it! There was a 7% decrease in their heart blockages on average (which results in 30% more blood flow by volume). Furthermore, when they looked only nine years into the study at the five patients that dropped out of the study to restart their “standard of care” treatment, they were found to have already had together 10 new coronary events.
Although the drug companies won’t pay for it or promote it, there is data out their supporting lifestyle change and disease reversal. Dr. Dean Ornish reported in the Lancet that significant lifestyle modification (without even using cholesterol medication) resulted in reversal (regression of disease on repeat angiogram) of blockages while the control group who did not make these changes showed worsening (progression) of disease in that same one-year period of time. What’s more, patients experienced a 91%, 45%, and 28% reduction in the frequency, duration, and severity of their angina respectively after just 3 weeks! Compare that to the control group who had 165%, 95%, and 39% INCREASE in their frequency, duration, and severity of their angina respectively. Tack onto these results the 20-pound weight loss and 20% cholesterol reduction (without medication) in the study group and these lifestyle changes should be a no brainer! In JAMA, Dr. Blankenhorn reported his study showing that significantly decreasing overall fat intake halted heart disease progression but changing the type of fat in the diet (ex: animal fat to olive oil), as most Americans do, did not halt progression. Even World War I and II autopsy studies demonstrated how significant dietary changes resulted in heart disease reversal. Unfortunately, most doctors overlook these important facts. Most doctors today fail to convey the importance and amazing healing potential of significant lifestyle modification because they are either unaware of the true benefit or they think patients lack the will or ability to make these changes...when in fact many patients just lack the proper support and direction.
We are not saying that people with heart disease are not sick or at risk of dying. They are definitely at risk of dying, but is bypass surgery the answer to their prayers? Does bypass surgery ever reverse heart disease? Does bypass surgery even help them live longer? And if it did, does it do so without a large price to pay…physically and financially? Rather than use the need for a heart intervention as a time for patients to try to get healthier, we just put a $40,000.00 band-aid on the problem. Furthermore, so many patients then use bypass as a get-out-of-jail-free card, returning to the same disease promoting diet and lifestyle that gave them their heart attack in the first place!
In the end, the heart surgery industry is a $100 billion a year industry supported by doctors, insurance companies, and drug companies. Unfortunately, medical intervention may not be the best choice for many symptomatic patients…especially those that are committed to actually getting healthier. We know that the incidence of heart disease is the same as it has been for the last 50 years (the same number of people each year are getting struck with the disease). And lately, according to the OECD, even the decline in heart disease deaths is slowing! Yet, with all of the fancy medical interventions and medications shouldn’t the decline in heart disease deaths be improving? It certainly should not be slowing! Shouldn’t heart disease deaths be a condition of the past (like the virtual eradication of polio after its vaccine was discovered)? With heart disease deaths stubbornly maintaining their #1 position, shouldn’t we look to new frontiers for treatment?
We certainly think so. Although we understand that some people may choose bypass surgery and that is their prerogative, we believe that for most people, there is no better place to start than with diet and lifestyle modification. If you think that is radical, ponder this…”What can be crazier or more radical than paying $40,000.00 to cut open your chest and risk 1 to 2 out of every 100 patients dying, all to do a procedure that has never been proven to actually make you live any longer?”
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Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H, Taylor HA, Chaitman BR. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation. 1995 May 1;91(9):2335-44.
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