Overdoing Heart Surgery?

The coronary bypass is unquestionably the most frequently performed piece of radical major surgery in the U.S. Some 25,000 times a year, doctors open the chest of a heart-disease victim to implant a piece of one of the patient's own veins or arteries to carry blood around an obstruction in the coronary artery that feeds the heart muscle. But is the bypass operation always necessary? Not according to Dr. Henry Russek, a professor of cardiology at New York Medical College. At a conference on cardiology at the Texas Heart Institute in Houston last week, Russek claimed that drugs and other forms of medical care are far better treatment than surgery for most cases of angina pectoris, the pains arising from the oxygen-starved heart muscle that can be forerunners of heart attacks. Said he: "More lives have been lost through bypass surgery than have been saved by it."

Russek's remarks touched a raw nerve among the surgeons attending the meeting. Boosters of the bypass operation credit it with saving at least 60,000 lives--most of them in the past five years --and offering new hope to heart-disease victims who might otherwise become cardiac cripples. The operation is now being performed at some 600 U.S. hospitals, and many surgeons believe that it should be used even more frequently.

Unlike numerous cardiologists who scorn surgery, Russek acknowledges the value of the coronary bypass in some cases. But he questions whether the operation is as safe as its advocates claim.

He notes that patients treated in one big-city institution have a 66% chance of dying on the operating table, ending up with a nonfunctioning graft or suffering major nonfatal postoperative complications. There are risks even at some of the university hospitals offering the operation. Though operating room mortality may be less than 5%, complications such as myocardial infarction (the classic heart attack), brain damage, hemorrhage, kidney failure or closure of the bypass are not uncommon. Despite these risks, Russek noted the tendency of some doctors to perform the operation as a "preemptive procedure" on patients who have not yet experienced angina or who suffer only mild symptoms.

Changing Life-Style. What bothers Russek the most, however, is the dearth of medical treatment preceding a decision to operate. Russek reviewed the medical treatment that had been given to 200 patients admitted to hospitals for surgery to correct uncontrollable angina. Nearly half had been treated with nothing other than nitroglycerin, a drug used to dilate or expand the arteries. In most of these cases, the drug had been used only to help abort an attack of angina--not to modify the conditions that led to the pain. On the other hand there had been insufficient effort to deal with either the physical conditions that cause angina pectoris or the life-style that eventually leads to it. "Taking medication, losing weight, giving up smoking and slowing down are unpleasant," Russek explains. "Most people would rather submit to an operation that promises to cure them quickly, even at the risk of death, than put up with medical management. Yet even after surgery these patients still need this kind of care." In fact, he suspects, some of the success of bypass surgery results from better medical management after the operation than the patient received before.

The rush to surgery, Russek feels, is self-destructive; good medical treatment is now available that can control the causes of angina and the crippling heart attacks that often follow. Russek treated one series of 102 patients suffering from severe angina for six years with a special combination of drugs: propranolol (Inderal), a drug that slows down the heart and reduces its need for oxygen, and long-acting nitrates that dilate the blood vessels and increase blood flow to the heart muscle. Only 1.2% of Russek's coronary patients died each year--about the same mortality rate from heart attacks as among apparently healthy people in the same age range.

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