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Cardiac Bypass, Angioplasty and Stenting by Jeffrey Dach MD

Posted Jan 14 2009 5:49pm
Coronary angiogram cardiac cath cardiology LAD left anterior descendingCardiac Bypass, Angioplasty and Stenting by Jeffrey Dach MD

No Reduction in Mortality or Heart Attacks   

The following thirty nine medical studies compare invasive treatment with conservative treatment of coronary artery disease.  Invasive treatment with bypass surgery, stent or angioplasty is compared  with conservative treatment with drugs.   These Thirty Nine Studies show that invasive treatment fails to reduce mortality or heart attacks, when compared to conservative medical treatment with drugs.

Brain Damage from Cardiac Bypass

Three studies in 1000 patients found that 50% of patients having bypass surgery have brain damage with permanent loss of memory and mental function.

Economic Benefits Make it Popular

Invasive treatment with bypass and angioplasty may not be the best treatment, yet is more likely to be offered because of the economic benefits.

Cardiac Bypass Operation with Surgeon holding Instruments Mortality IS REDUCED in A limited Number of Cases

Coronary Bypass has been found to prolong life in the limited number of cases who have both left main coronary disease and reduced ejection fraction.  However, if Left Ventricluar function is normal (i.e. normal ejection fraction), then bypass does not affect over all mortality compared to medical treatment.

Left Image Cardiac Bypass courtesy of Wikimedia Commons


Above information courtesy of Howard H. Wayne, M.D.   



Thirty Nine Studies

Non-Q-wave Myocardial Infarction Following Thrombolytic Therapy

Percutaneous Transluminal Angioplasty Versus Medical Treatment For Non-Acute Coronary Heart Disease

An Invasive Strategy Reduced Death, Myocardial Infarction and Readmissions in Unstable Coronary Artery Disease

Intensive Medical Therapy Versus Coronary Angioplasty for Suppression of Myocardial Ischemia in Survivors of an Acute Myocardial Infarction

Outcome In Patients with Acute Non-Q Wave Myocardial Infarction Randomly Assigned to An Invasive As Compared with a Conservative Management Strategy

Twenty-two Year Follow-up in the VA Cooperative Study of Coronary artery bypass surgery for Stable Angina

A Prospective Randomized Trial of Triage Angiography in Acute Coronary Syndromes Ineligible for Trombolytic Therapy

Danish Multicenter Randomized Study of Invasive Versus Conservative Treatment In Patients With Inducible Ischemia After Thrombolysis In Acute Myocardial Infarction

Coronary Angioplasty Versus Medical Therapy For Angina

One Year Results of the Thrombolysis in Myocardial Infarction (TIMI)IIIB Clinical Trial

The Medicine, Angioplasty or Surgery Study (MASS)

The TIMI IIIB Investigators

Two and Three Year Results of the Thrombolysis in Myocardial Infarction (TIMI) Phase II Clinical Trial

Randomized Trial of Late Angioplasty Versus Conservative Management For Patients with Residual Stenosis After Thrombolytic Treatment of Myocardial Infarction

A Comparison of Angioplasty With Medical Therapy in the Treatment of Single Vessel Coronary Artery Disease

SWIFT Trial of Delayed Elective Intervention v. Conservative Treatment After Thrombolysis With Anistreplase in Acute Myocardial Infarction

Comparison of Immediate Invasive, Delayed Invasive and Conservative Strategies After Tissue-Type Plasminogen Activator

Randomized Controlled Trial of Late In-Hospital Angiography and Angioplasty Versus Conservative Management After Treatment With Recombinant Tissue-Type Plasminogen Activator in Acute Myocardial Infarction

Comparison of Invasive and Conservative Strategies After Treatment With Intravenous Tissue Plasminogen Activator in Acute Myocardial Infarction

Thrombolysis With Tissue Plasminogen Activator in Acute Myocardial Infarction: No Additional Benefit From Immediate Percutaneous Coronary Angioplasty

Comparison of Medical and Surgical Treatment for Unstable Angina Pectoris

Racial Differences in the Use of Invasive Cardiac Procedures and 1 Year Clinical Outcomes for Non-Q-Wave Myocardial Infarction Patients Randomized to Invasive vs. Conservative Management

A Comparison of the Impact of Practice Patterns on Outcome of Patients With Acute Coronary Syndromes in the USA and Canada: Post Hoc Analysis of ESSENCE and TIMI IIB

Outcome Study of Two Large Populations With Different Rates of Cardiac Interventions

Piegas, IS, Flather, M, Pogue J. et al. for the OASIS Registry Investigators

Comparison of Medical Care and Survival of Hospitalized Patients with Acute Myocardial Infarction in Poland and the United States

Use of Coronary Angiography and Revascularization Procedures Following Acute Myocardial Infarction: A European perspective

Use of Cardiac Procedures and Outcomes in Elderly Patients with Myocardial Infarction in the United States and Canada

Variation in the Use of Cardiac Procedures After Acute Myocardial Infarction

A Comparison of Management Patterns After Acute Myocardial Infarction in Canada and in the United States

Differences in the Treatment of Myocardial Infarction in the United States and Canada. A Comparison of Two University Hospitals

Comparison of Medical Care and One and 12 Month Mortality of Hospitalized patients with Acute Myocardial Infarction in Minneapolis-St. Paul, Minnesota, United States of America and Goteborg, Sweden

Longitudinal Assessment of Neurocognitive Function After Coronary Artery Bypass Surgery

Coronary Stenting or Percutaneous Transluminal Coronary Angioplasty Prior to Noncardiac Surgery Increases Adverse Events: The Evidence is Mounting

Catastrophic Outcomes of Noncardiac Surgery Soon After Coronary Stenting

Results of a Second-Opinion Trial Among Patients Recommended For Coronary Angiography

Two to Eight Year Survival Rates in Patients Who Refused Coronary Artery Bypass Grafting

Prognosis of Medically Treated Patients with Coronary Artery Disease With Profound ST-Segment Depression During Exercise Testing

Exercise Performance-Based Outcomes of Medically Treated Patients with Coronary Artery Disease and Profound ST Segment Depression


References

http://online.wsj.com/article/SB123146318996466585.html  
Wall Street Journal Jan 2009

In 2006, for example, according to data provided by the American Heart Association, 1.3 million coronary angioplasty procedures were performed at an average cost of $48,399 each, or more than $60 billion; and 448,000 coronary bypass operations were performed at a cost of $99,743 each, or more than $44 billion. In other words, Americans spent more than $100 billion in 2006 for these two procedures alone.

Despite these costs, a randomized controlled trial published in April 2007 in The New England Journal of Medicine found that angioplasties and stents do not prolong life or even prevent heart attacks in stable patients (i.e., 95% of those who receive them). Coronary bypass surgery prolongs life in less than 3% of patients who receive it. So, Medicare and other insurers and individuals pay billions for surgical procedures like angioplasty and bypass surgery that are usually dangerous, invasive, expensive and largely ineffective. Yet they pay very little -- if any money at all -- for integrative medicine approaches that have been proven to reverse and prevent most chronic diseases that account for at least 75% of health-care costs. The INTERHEART study, published in September 2004 in The Lancet, followed 30,000 men and women on six continents and found that changing lifestyle could prevent at least 90% of all heart disease.

http://www.drmcdougall.com/misc/2007nl/apr/fav5.htm   Angioplasty Fails Again and Again (8 out of 8 times)

Optimal Medical Therapy with or without PCI for Stable Coronary Disease by William Boden  in the April 12, 2007 issue of the New England Journal of Medicine found after studying 2287 patients, “As an initial management strategy in patients with stable coronary artery disease, PCI (angioplasty) did not reduce the risk of death, myocardial infarction,
or other major cardiovascular events when added to optimal medical therapy.”1

In 2004, more than 1 million coronary stent procedures were performed in the United States, and recent registry data indicate that approximately 85% of all PCI procedures are undertaken electively in patients with stable coronary artery disease.

1) http://content.nejm.org/cgi/content/short/NEJMoa070829
Boden WE, et al.  Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007 Apr 12;356(15):1503-16.

2) http://www.bmj.com/cgi/content/full/334/7596/0-a
Loder E. Curbing Medical Enthusiasm. BMJ 2007, April 7; 334: doi:10.1136/bmj.39175.409132.3A

3) http://content.nejm.org/cgi/content/abstract/NEJMoa066139
Hochman JS, Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006 Dec 7;355(23):2395-407.

4) http://content.nejm.org/cgi/content/extract/356/15/1572
Hochman JS, Steg PG.  Does preventive PCI work? N Engl J Med. 2007 Apr 12;356(15):1572-4.

The study I am now writing about in this newsletter brings the total to 8 studies reported to date that show angioplasty fails to save lives—there are no others showing otherwise.

http://content.nejm.org/cgi/content/short/NEJMoa070829
Optimal Medical Therapy with or without PCI for Stable Coronary Disease William E. Boden, M.D., the COURAGE Trial Research Group 
    
Background In patients with stable coronary artery disease, it remains unclear whether an initial management strategy of percutaneous coronary intervention (PCI) with intensive pharmacologic therapy and lifestyle intervention (optimal medical therapy) is superior to optimal medical therapy alone in reducing the risk of cardiovascular events.

Methods We conducted a randomized trial involving 2287 patients who had objective evidence of myocardial ischemia and significant coronary artery disease at 50 U.S. and Canadian centers. Between 1999 and 2004, we assigned 1149 patients to undergo PCI with optimal medical therapy (PCI group) and 1138 to receive optimal medical therapy alone (medical-therapy group). The primary outcome was death from any cause and nonfatal myocardial infarction during a follow-up period of 2.5 to 7.0 years (median, 4.6).

Results There were 211 primary events in the PCI group and 202 events in the medical-therapy group. The 4.6-year cumulative primary-event rates were 19.0% in the PCI group and 18.5% in the medical-therapy group (hazard ratio for the PCI group, 1.05; 95% confidence interval [CI], 0.87 to 1.27; P=0.62). There were no significant differences between the PCI group and the medical-therapy group in the composite of death, myocardial infarction, and stroke (20.0% vs. 19.5%; hazard ratio, 1.05; 95% CI, 0.87 to 1.27; P=0.62); hospitalization for acute coronary syndrome (12.4% vs. 11.8%; hazard ratio, 1.07; 95% CI, 0.84 to 1.37; P=0.56); or myocardial infarction (13.2% vs. 12.3%; hazard ratio, 1.13; 95% CI, 0.89 to 1.43; P=0.33).

Conclusions As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy. (ClinicalTrials.gov number,

http://content.nejm.org/cgi/content/abstract/297/12/621  
Treatment of chronic stable angina.  NEJM Volume 297:621-627  September 22, 1977  Number 12.   A preliminary report of survival data of the randomized Veterans Administration cooperative study
ML Murphy, HN Hultgren, K Detre, J Thomsen, and T Takaro 

We evaluated the effect of saphenous-vein-bypass grafting on survival in patients with chronic stable angina by comparing medical and surgical treatment in a large-scale, prospective randomized study. Excluding patients with left-main-coronary-artery disease who have already been reported, a total of 596 patients were entered into this study; when randomized into a medical group (310 patients) and a surgical group (286 patients), entry clinical and angiographic base lines were comparable. Operative mortality at 30 days was 5.6 per cent. At an average of one year after operation, 69 per cent of all grafts were patent, and 88 per cent of the surgical patients had atleast one patent graft. There was no statistically significant difference in survival, at a minimal follow-up interval of 21 months, between patients treated medically and those treated with saphenous-vein-bypass grafting. A t 36 months, 87 per cent of the medical group and 88 per cent of the surgical group were alive.

http://www.ncbi.nlm.nih.gov/pubmed/6608052?dopt=Abstract
NEJM 1984 Mar 22;310(12):750-8
Myocardial infarction and mortality in the coronary artery surgery study (CASS) randomized trial.

The long-term benefit of coronary bypass surgery in terms of longevity and prevention of major ischemic events in patients who have mild angina is not well defined. The randomized Coronary Artery Surgery Study (CASS) was designed to evaluate this issue; it consists of 780 patients who were considered operable and who had mild stable angina pectoris or who were free of angina after infarction. As a result of the randomization process there were no significant differences in base-line variables between patients randomly assigned to medical and to surgical therapy. The likelihood of death in the five-year period after randomization was only 8 per cent in the medical cohort, as compared with 5 per cent in the surgical cohort (not significant). The likelihood of nonfatal Q-wave myocardial infarction was 11 and 14 per cent, respectively (not significant). The five-year probability of remaining alive and free of infarction was 82 per cent in the patients assigned to medical therapy and 83 per cent in the patients assigned to surgery (not significant). There were no statistically significant differences in the survival rate or in the myocardial-infarction rate between subgroups of patients randomly assigned to medical and to surgical therapy when they were analyzed according to initial group assignment, number of diseased vessels, or ejection fraction. Therefore, as compared with medical therapy, coronary bypass surgery appears neither to prolong life nor to prevent myocardial infarction in patients who have mild angina or who are asymptomatic after infarction in the five-year period after coronary angiography.

http://www.ncbi.nlm.nih.gov/pubmed/6128492?dopt=Abstract  
LAncet 1982 Nov 27;2(8309):1173-80. Long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. European Coronary Surgery Study Group.

This report presents the final results (follow-up 5--8 years) of a prospective study in 768 men aged under 65 with mild to moderate angina, 50% or greater stenosis in at least two major coronary arteries, and good left ventricular function. 395 were randomised to coronary artery bypass surgery, 373 to no treatment; 1 patient in the surgery group was lost to follow-up. These original groups were compared, whatever subsequently happened to the patients. Survival was improved significantly by surgery in the total population, in patients with three-vessel disease, and in patients with stenosis in the proximal third of the left anterior descending artery constituting a component of either two or three vessel disease, and non-significantly in patients with left main coronary disease. An abnormal electrocardiogram at rest, ST-segment depression greater than or equal to 1.5 mm during exercise, peripheral arterial disease, and increasing age independently point to a better chance of survival with surgery. In the absence of these prognostic variables in patients with either two or three vessel disease the outlook is so good that early surgery is unlikely to increase the prospect of survival. In terms of anginal attacks, use of beta-adrenergic blockers and nitrates, and exercise performance the surgical group did significantly better than the medical group throughout the 5 years of follow-up, but the difference between the two treatments tended to decrease.

http://www.heartprotect.com/comparison-studies.shtml
COMPARISON OF INVASIVE VS. NONINVASIVE THERAPIES AND RELATED STUDIES

Jeffrey Dach MD
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(c) 2009 Jeffrey Dach MD All Rights Reserved
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