Heart attacks - stents vs bypass surgery

Ten years ago I was told that I had to have stents put into some of my coronary arteries before I could have surgery because the arteries were blocked and, if I didn't, I could have a heart attack and die during surgery. I did some research on stents. In those days they were still pretty experimental and were solid metal tubes used to keep the arteries open. I decided against the procedure and my doctor told me that he would not "sign off on" (i.e. approve) my surgery.

The surgery was to reverse a colostomy which I'd had the year before due to diverticulitis and I was determined to have it removed. The colostomy was not nearly as horrific as I had expected but it was inconvenient. It's much easier to poop out of the hole the God created for that purpose than to poop in a plastic bag glued to raw intestine coming through a hole in your belly.

I was lucky that I had a friend, a cardiologist who was as skeptical about new procedures as I was. He agreed to "sign off on" the surgery without my having to have stents. And, yes, I did "die" during surgery but fortunately was resuscitated. Then the bad reviews of the old solid metal stents started coming in and I thanked God that I had been skeptical about them. I kept reading about "stent failures" which was basically code for "oops!"

Then, three years ago I had a heart attack and was told again that I had to have stents. By now the stents were made of mesh and were coated with blood-thinning clot-busting drugs. They also were experimental (introduced in 2003) and I was very reluctant but I knew that I was dying anyway and didn't have another option. I had three stents placed in my heart. They saved my life.

Now the reviews of the "new improved" stents is coming in and the news is mixed. From Heart bypass better than stents, study says:

LOS ANGELES - Bypass surgery remains the best option for heart patients with more than one clogged artery, according to the first big study to compare bypass with drug-coated stents.

The new research dims hopes that the less drastic stent procedure would prove to be just as good for people with multiple blockages.

In the study, heart attack and death rates were lower among people who had surgery than those given artery-opening balloon angioplasty and stents — mesh cylinders oozing drugs to keep vessels from reclogging.

It is latest setback for drug-coated stents, which have revolutionized heart care and have been implanted in about 6 million people worldwide. They are far better at keeping vessels open than older bare metal stents. However, sales have been hurt in the past year by safety concerns and studies questioning the value of angioplasty itself for certain patients.

A second study gave stent makers some good news, finding that using these devices “off label,” in non-approved situations, is not as dangerous as many had feared.

Both studies were published in Thursday’s New England Journal of Medicine. Neither is definitive enough to resolve these issues, but they help guide doctors and patients confused about which treatment is best for whom.

Blocked arteries cause chest pain by depriving the heart of needed blood, and can lead to a heart attack. One solution is bypass surgery, which reroutes blood vessels to detour around blockages. Angioplasty has emerged as a non-surgical alternative, in which a balloon is pushed into a blood vessel and inflated to flatten the clog, and stents are placed to keep the artery open.

Bypass has become less common as angioplasty has risen dramatically. In 2005, about 469,000 bypasses were performed on 261,000 patients. More than 1.2 million angioplasties were done, though many people had more than one procedure.

Bypass patients had fewer heart attacks
Researchers analyzed two state databases of 17,400 New York residents treated for multiple blockages in 2003 and 2004, and compared deaths and complications 18 months later.

Survival rates for both treatments were excellent, but bypass still showed a significant advantage after researchers took into account differences in how sick or old the patients were.

People with three clogged arteries had a survival rate of 94 percent after bypass compared with about 93 percent after stenting, which translated to a 20 percent lower risk of death. Those with two blockages had a survival rate of 96 percent after the operation compared with roughly 95 percent after stenting — about a 30 percent lower risk of death. The bypass group also needed fewer repeat procedures and suffered fewer heart attacks after treatment.

Medicine is all about risk assessment and trade-offs and "a survival rate of 94 percent after bypass compared with about 93 percent after stenting" sounds pretty good to me considering that stenting is done by cutting a slit in the artery in your groin and inserting a tube from there to the heart which then places the stent in the artery while bypasses are done by cutting into the chest and sawing open the ribs to get to the to the heart and then cutting, rerouting and re-attaching the coronary arteries.