At the “heart” of the issue whether a bypass makes a difference is the question of mechanism. Restoring oxygenated blood supply to muscle should be protective. Does the failure of the trials to demonstrate any significant difference point to a lack of basic understanding of the biological mechanism or the ineffectiveness of the procedure to restore adequate amount of oxygenated blood to the tissue? Totally confused but have a personal stake in this.
John's article is yet another example of the insignificant role of evidence in healthcare decision-making. Will it ever change?
The American College of Cardiology and American Heart Association (ACC/AHA) recently revised their CABG guidelines, something cardiac patients will never read or understand. As expected, the American Association for Thoracic Surgery and the Society of Thoracic Surgeons did not endorse these changes. Concerns surrounding CABG for stable angina have been around for years.
One contributing factor is the American healthcare consumer's inclination to favor the newest, most technologically advanced, and most expensive treatments. It's akin to handing someone a credit card at an auto mall and telling someone they can choose whatever car they want. Many of us could buy a Honda Civic but choose a luxury car simply because we are not footing the bill.
Second are perverse reimbursement incentives for providers. Thoracic surgeons in the United States earn around $500,000 annually, usually based on the number of surgeries they perform. The more one does, the more one makes. As Upton Lewis said, “It is difficult to get a man to understand something when his salary depends on his not understanding it.”
Finally, the substantial cost of CABG complications is rarely discussed in the media. A study spanning 18 hospitals and cardiac surgical practices in Virginia from January 2006 to December 2015 revealed that the 10-year cost of complications in CABG was significant. Cardiac surgery centers in the study spent over $78.6 million on CABG complications, with prolonged ventilation accounting for the highest cost at $59.1 million due to its frequent occurrence.
It is not a simple as who gets this and who gets that treatment Not all patients are treated to those values were risk regresses to zero for the future development of atherosclerotic disease, nor is surgery always as complete as needs be. It does not mean that the listed studies are of no value, but it does suggest that they not be over interpreted one way or the other. All of medicine is guesswork and the best doctors have the best guessing rate.
In 2003 I published an article in the American Journal of cardiology where I had followed 20 consecutive patients for 20 years following their open heart surgery (surgery 1983 or before). Based on aggressive medical risk reduction attempting in all to reach a non-HDL cholesterol of 90 or less and triglycerides of 100 or less, there was not one repeat angioplasty or bypass surgery in that group.
I am a lot older than Mandrola. The phrase "widow maker" was originally applied to hemodynamically significant obstruction in the left main. But apparently such a cool phrase was not being used often enough and so the definition was changed to the still very important, but less dramatic, but more frequent tight proximal LAD stenosis, hence allowing the use of that cool phrase more often.
It is very interesting that the first story is about a male with Coronary Artery Disease who didn't have the surgery but later only took a few medications/ tablets and only had minor symptoms and was overall okay. How does that happen? Was there something else occurring?
Besides all indications for CABG as mentioned at the last column by JMM. The patients with Diabetes mellitus with Severe CAD do better with CABG vs medical therapy including medical revascularization.
This actually makes me angry. My 82yo father went in for a triple bipass in early 2020 on his doctor’s recommendation and had a series of mini strokes on the table that affected his balance and a bit of his memory. His recovery was impacted and then everything went into lockdown in early March, again effecting his recovery. He now says he wishes he wouldn’t have had the procedure done, he doesn’t see how it did any good. Seeing these charts just makes my blood boil. How can we trust anything doctors recommend?
I am having a hard time imagining what would motivate me to recommend major surgery to an 82 year old man---especially when there are much less invasive procedures such as stenting. I suspect your anger is justified.
I had the same thought. But, an elderly grandmother in my extended family had several vessel bypass after heart attack at age 83 and subsequently lived well and healthy, all apparent faculties intact, to just two months shy of 100. It's a judgment call what to do with a given patient, but this essay warns us to choose our doctors and treatments with due caution and as much information as we need when stakes are high. Even small decisions such as whether to take a pill with a certain negative side effect warrant this caution.
Former thoracic surgeon, here. I was aware of the studies reviewed, but never looked into them in any detail, to my discredit. Still, my experience was largely consistent with John's review. CABG was offered as an option for patients with stable angina, but, as a means of ameliorating symptoms, not prolonging life. The cardiologists I most admired were the ones who first emphasized medical management, and the stable angina referrals I received from them were for refractory symptoms despite optimal medical management.
CABG was more strongly considered for those with multi-vessel disease in the setting of diminished LV function, proximal LAD stenoses, or left main disease, but still as an option for patients with stable angina. And, of course, it was more commonly recommended for those with unstable angina not amenable to percutaneous intervention; but unstable disease is almost an entirely different beast. The referrals we thoracic surgeons least appreciate, however, is for those patients with diminished LV function and multi-vessel disease who have failed prior stent procedures, and are not infrequently now presenting with unstable symptoms.
There's something I don't understand but before I get to that, let me first say the acronyms you docs devise to name your studies puts me in STITCHES! 🤣 So here's what I don't understand. You said, "The main take-home of this post is to emphasize the extreme (near-miraculous) stability of stable coronary disease." I've seen frequent references to "stable coronary artery disease (CAD)," but have never seen it defined. So I decided to ask Mr. Google, and found the article below which informed me the concept is a myth. Unfortunately, I couldn't evaluate its analysis since it's behind a paywall. I found several articles that defined it as "a reversible supply-demand mismatch related to ischemia, precipitated by the presence of atherosclerotic plaques within the epicardial coronary arteries." Well, how would you know that unless you have angina or a heart attack? I know quite a few people who have had CABG, and for all of them, it was done after a heart attack caused by blockage they didn't know they had. You're not big on coronary screenings when no symptoms are present, but for many people, their first symptom is a heart attack. So if most bypasses are done during or after a heart attack, wouldn't that be appropriate? Because that's moved beyond the "stable" stage, hasn't it? I don't have a vested interest, not being a physician. I just want to know if/when it would be appropriate to get a bypass.
The article you cited doesn't actually claim that stable coronary artery disease is a myth (though it's in the title), they just wish to reclassify it as chronic coronary artery disease. Their point, I guess, is to emphasize that chronic (stable) coronary artery disease is an ongoing risk that needs to be optimally managed. Nothing new there, really.
When we talk about stable v unstable coronary artery disease, we're referring to the presenting symptoms, and making assumptions (probably usually valid) regarding the underlying process.
Stable coronary artery disease consists of atherosclerotic plaques that may be causing no symptoms, or may be responsible for stable angina, due to mismatch between oxygen demand by heart muscle and delivery by partially blocked arteries. In this case, the mismatch is reversible, as the plaques don't change suddenly, and the symptoms usually resolve with rest and/or medications.
Unstable coronary artery disease, in contrast, is thought due to rupture of those atherosclerotic plaques, leading to debris and/or thrombus within the affected coronary artery, leading to unstable angina (symptoms don't resolve with rest and medications and with persistent signs on ECG) or myocardial infarction (heart attack).
There is overlap between these conditions, however. People with longstanding stable disease can have a plaque rupture and develop a heart attack. Those presenting with unstable angina may be stabilized with mediations and/or stents, and then their disease may become stable (chronic, per the Nature article) with ongoing medial care. We think that one of the benefits of statin therapy has less to do with improving blood cholesterol levels and more with helping to stabilize plaques, making them less prone to rupture, for example.
John or others can correct anything I got wrong...
Thanks for the info, doc. I guess even Nature is now semi-susceptible to hyping their headlines but not sure why, since an article that can only be accessed via a paywall is not exactly "click bait!" Chronic sounds like a good name, although I thought any kind of heart disease is chronic. I have read that statins stabilize plaque by calcifying them, so I guess it's pointless to do another CAC score once you've begun a statin. I'm on a statin (CAC score of 34 but LAD = 0). Hopefully neither I nor my spouse, who also recently started a statin after getting a CAC of 97, will ever be recommended a stent, because I'm still confused whether it would be helpful or not. But I'll keep your comments and John's for future reference, and hope we never have to decide. Despite what John says about CAC scores, they are the reason we decided to take a statin. We're good about lifestyle except when UPF is around, which I try not to be around TOO much!
Yet another “wow”…to follow all the “wows” I’ve been experiencing from the reviews on the Cardiology Trials substack.
This is still from an era before my training time…and was considered “settled science” by that point….little did I know that the motherhood teaching of CABG for LM or 3VD came from subgroups of a meta-analysis.
This area also seems ripe for a revisit. The data doesn’t seem terribly strong to begin with, and seems reasonable to wonder about an expiration date. Modern CABG techniques Vs modern meds for LM or 3VD would be interesting.
In 2014, my EP discovered an aneurysm (4.5 cm) on my ascending aorta. At the same time, I was told my LAD was 99% blocked. I was given the choice of mesh repair of the distended artery, along with a standard bypass procedure on LAD (requiring open heart surgery) -- or watchful waiting. Not wanting a future life of "tiptoeing on eggshells," I opted for the surgery. As an added enticement, I was told that if I chose the open heart procedure, the surgeon (a famed Houston doctor who was a protege of the god-like Michael DeBakey) would also attempt a myectomy to reduce the non-obstructive HCM in my left ventricle. Encouraged by the confident demeanor of the surgeon and his impressive credentials, I agreed to the full-Monty. (I was also told that the doctors would attempt to ablate my A-fib "while they were in there.") The entire procedure took 6 1/2 hours and I spend 2-3 days in IC for recovery (a horrible experience). The bill came to more than half-a-million dollars, which (thank goodness!) Medicare paid. Fast forward to the summer of 2022 when I was experiencing myocarditis-like symptoms after taking the Covid vax (an "impossible" connection my cardiologist stated, given my 70+ age and the "fact" that vax-induced myocarditis only affects young men). Insisting on further examination, my doc complied by ordering arthroscopy which discovered a couple of interesting situations. First, the heart muscle of my apex was found to be necrotic (dead) and therefore not pulsing to improve the volume of blood/circulation from my left ventricle, as the myectomy had intended. Second, the scan showed that the 2014 LAD bypass had completely failed and that the blood flow was traveling through the original LAD (which, incidentally, now showed to be only 70% blocked -- not the 99% that the 2014 diagnosis stated) and was capably carrying the load during my current daily bouts of intense exercise). Finally, I awoke from my $500K+ surgery with a (surprise!) pacemaker, suggesting that perhaps the attempted ablations of my A-fib had been irreparably botched and therefore "covered" by the pacing device. Since my surgery, I began wondering how many other "life-saving" medical procedures have been performed on countless trusting patients solely to enrich the hospital and doctors involved? And if the old saying might actually be true that "doctors bury their mistakes." Over the recent decdes, we've herd about countless cases of needless stenting and bypass procedures performed on innocent patients who haven't been helped one iota by these practices. Furthermore, we've had no convincing scientific data that these procedures are life-saving or even helpful (except in the instances of an actual MI in progress). Performing unnecessary surgical procedures on unsuspecting patients should be a punishable crime -- and the physicians who profit should be treated like the criminals that they are. Indeed, the willful ignorance on the part of the entire practice of cardiology by condoning these practices and not actively seeking scientific proof of their efficacy should be called into public examination. When will there be a reckoning or justice? When will cardiology reform itself? When will individual practitioners "come clean?' Tragically, not in my lifetime, I dare say.
At the “heart” of the issue whether a bypass makes a difference is the question of mechanism. Restoring oxygenated blood supply to muscle should be protective. Does the failure of the trials to demonstrate any significant difference point to a lack of basic understanding of the biological mechanism or the ineffectiveness of the procedure to restore adequate amount of oxygenated blood to the tissue? Totally confused but have a personal stake in this.
John's article is yet another example of the insignificant role of evidence in healthcare decision-making. Will it ever change?
The American College of Cardiology and American Heart Association (ACC/AHA) recently revised their CABG guidelines, something cardiac patients will never read or understand. As expected, the American Association for Thoracic Surgery and the Society of Thoracic Surgeons did not endorse these changes. Concerns surrounding CABG for stable angina have been around for years.
One contributing factor is the American healthcare consumer's inclination to favor the newest, most technologically advanced, and most expensive treatments. It's akin to handing someone a credit card at an auto mall and telling someone they can choose whatever car they want. Many of us could buy a Honda Civic but choose a luxury car simply because we are not footing the bill.
Second are perverse reimbursement incentives for providers. Thoracic surgeons in the United States earn around $500,000 annually, usually based on the number of surgeries they perform. The more one does, the more one makes. As Upton Lewis said, “It is difficult to get a man to understand something when his salary depends on his not understanding it.”
Finally, the substantial cost of CABG complications is rarely discussed in the media. A study spanning 18 hospitals and cardiac surgical practices in Virginia from January 2006 to December 2015 revealed that the 10-year cost of complications in CABG was significant. Cardiac surgery centers in the study spent over $78.6 million on CABG complications, with prolonged ventilation accounting for the highest cost at $59.1 million due to its frequent occurrence.
https://www.jtcvs.org/action/showPdf?pii=S0022-5223%2817%2932388-7
Survival curves don't tell the whole story. Has there been a good study regarding quality of life in both arms?
It is not a simple as who gets this and who gets that treatment Not all patients are treated to those values were risk regresses to zero for the future development of atherosclerotic disease, nor is surgery always as complete as needs be. It does not mean that the listed studies are of no value, but it does suggest that they not be over interpreted one way or the other. All of medicine is guesswork and the best doctors have the best guessing rate.
In 2003 I published an article in the American Journal of cardiology where I had followed 20 consecutive patients for 20 years following their open heart surgery (surgery 1983 or before). Based on aggressive medical risk reduction attempting in all to reach a non-HDL cholesterol of 90 or less and triglycerides of 100 or less, there was not one repeat angioplasty or bypass surgery in that group.
I am a lot older than Mandrola. The phrase "widow maker" was originally applied to hemodynamically significant obstruction in the left main. But apparently such a cool phrase was not being used often enough and so the definition was changed to the still very important, but less dramatic, but more frequent tight proximal LAD stenosis, hence allowing the use of that cool phrase more often.
It is very interesting that the first story is about a male with Coronary Artery Disease who didn't have the surgery but later only took a few medications/ tablets and only had minor symptoms and was overall okay. How does that happen? Was there something else occurring?
Besides all indications for CABG as mentioned at the last column by JMM. The patients with Diabetes mellitus with Severe CAD do better with CABG vs medical therapy including medical revascularization.
This actually makes me angry. My 82yo father went in for a triple bipass in early 2020 on his doctor’s recommendation and had a series of mini strokes on the table that affected his balance and a bit of his memory. His recovery was impacted and then everything went into lockdown in early March, again effecting his recovery. He now says he wishes he wouldn’t have had the procedure done, he doesn’t see how it did any good. Seeing these charts just makes my blood boil. How can we trust anything doctors recommend?
I am having a hard time imagining what would motivate me to recommend major surgery to an 82 year old man---especially when there are much less invasive procedures such as stenting. I suspect your anger is justified.
I had the same thought. But, an elderly grandmother in my extended family had several vessel bypass after heart attack at age 83 and subsequently lived well and healthy, all apparent faculties intact, to just two months shy of 100. It's a judgment call what to do with a given patient, but this essay warns us to choose our doctors and treatments with due caution and as much information as we need when stakes are high. Even small decisions such as whether to take a pill with a certain negative side effect warrant this caution.
AS you note, these trials were using outdated approaches to medical (and also surgical) therapy. Can we guess what the results would look like today?
I appreciate your work in addressing how often the more aggressive approach is actually warranted.
Thanks for these thought-provoking articles and thanks to all readers who provide their experience and feedback.
Former thoracic surgeon, here. I was aware of the studies reviewed, but never looked into them in any detail, to my discredit. Still, my experience was largely consistent with John's review. CABG was offered as an option for patients with stable angina, but, as a means of ameliorating symptoms, not prolonging life. The cardiologists I most admired were the ones who first emphasized medical management, and the stable angina referrals I received from them were for refractory symptoms despite optimal medical management.
CABG was more strongly considered for those with multi-vessel disease in the setting of diminished LV function, proximal LAD stenoses, or left main disease, but still as an option for patients with stable angina. And, of course, it was more commonly recommended for those with unstable angina not amenable to percutaneous intervention; but unstable disease is almost an entirely different beast. The referrals we thoracic surgeons least appreciate, however, is for those patients with diminished LV function and multi-vessel disease who have failed prior stent procedures, and are not infrequently now presenting with unstable symptoms.
Yeah, I really don't miss all that...
There's something I don't understand but before I get to that, let me first say the acronyms you docs devise to name your studies puts me in STITCHES! 🤣 So here's what I don't understand. You said, "The main take-home of this post is to emphasize the extreme (near-miraculous) stability of stable coronary disease." I've seen frequent references to "stable coronary artery disease (CAD)," but have never seen it defined. So I decided to ask Mr. Google, and found the article below which informed me the concept is a myth. Unfortunately, I couldn't evaluate its analysis since it's behind a paywall. I found several articles that defined it as "a reversible supply-demand mismatch related to ischemia, precipitated by the presence of atherosclerotic plaques within the epicardial coronary arteries." Well, how would you know that unless you have angina or a heart attack? I know quite a few people who have had CABG, and for all of them, it was done after a heart attack caused by blockage they didn't know they had. You're not big on coronary screenings when no symptoms are present, but for many people, their first symptom is a heart attack. So if most bypasses are done during or after a heart attack, wouldn't that be appropriate? Because that's moved beyond the "stable" stage, hasn't it? I don't have a vested interest, not being a physician. I just want to know if/when it would be appropriate to get a bypass.
https://www.nature.com/articles/s41569-019-0233-y
The article you cited doesn't actually claim that stable coronary artery disease is a myth (though it's in the title), they just wish to reclassify it as chronic coronary artery disease. Their point, I guess, is to emphasize that chronic (stable) coronary artery disease is an ongoing risk that needs to be optimally managed. Nothing new there, really.
When we talk about stable v unstable coronary artery disease, we're referring to the presenting symptoms, and making assumptions (probably usually valid) regarding the underlying process.
Stable coronary artery disease consists of atherosclerotic plaques that may be causing no symptoms, or may be responsible for stable angina, due to mismatch between oxygen demand by heart muscle and delivery by partially blocked arteries. In this case, the mismatch is reversible, as the plaques don't change suddenly, and the symptoms usually resolve with rest and/or medications.
Unstable coronary artery disease, in contrast, is thought due to rupture of those atherosclerotic plaques, leading to debris and/or thrombus within the affected coronary artery, leading to unstable angina (symptoms don't resolve with rest and medications and with persistent signs on ECG) or myocardial infarction (heart attack).
There is overlap between these conditions, however. People with longstanding stable disease can have a plaque rupture and develop a heart attack. Those presenting with unstable angina may be stabilized with mediations and/or stents, and then their disease may become stable (chronic, per the Nature article) with ongoing medial care. We think that one of the benefits of statin therapy has less to do with improving blood cholesterol levels and more with helping to stabilize plaques, making them less prone to rupture, for example.
John or others can correct anything I got wrong...
Thanks for the info, doc. I guess even Nature is now semi-susceptible to hyping their headlines but not sure why, since an article that can only be accessed via a paywall is not exactly "click bait!" Chronic sounds like a good name, although I thought any kind of heart disease is chronic. I have read that statins stabilize plaque by calcifying them, so I guess it's pointless to do another CAC score once you've begun a statin. I'm on a statin (CAC score of 34 but LAD = 0). Hopefully neither I nor my spouse, who also recently started a statin after getting a CAC of 97, will ever be recommended a stent, because I'm still confused whether it would be helpful or not. But I'll keep your comments and John's for future reference, and hope we never have to decide. Despite what John says about CAC scores, they are the reason we decided to take a statin. We're good about lifestyle except when UPF is around, which I try not to be around TOO much!
Yet another “wow”…to follow all the “wows” I’ve been experiencing from the reviews on the Cardiology Trials substack.
This is still from an era before my training time…and was considered “settled science” by that point….little did I know that the motherhood teaching of CABG for LM or 3VD came from subgroups of a meta-analysis.
This area also seems ripe for a revisit. The data doesn’t seem terribly strong to begin with, and seems reasonable to wonder about an expiration date. Modern CABG techniques Vs modern meds for LM or 3VD would be interesting.
In 2014, my EP discovered an aneurysm (4.5 cm) on my ascending aorta. At the same time, I was told my LAD was 99% blocked. I was given the choice of mesh repair of the distended artery, along with a standard bypass procedure on LAD (requiring open heart surgery) -- or watchful waiting. Not wanting a future life of "tiptoeing on eggshells," I opted for the surgery. As an added enticement, I was told that if I chose the open heart procedure, the surgeon (a famed Houston doctor who was a protege of the god-like Michael DeBakey) would also attempt a myectomy to reduce the non-obstructive HCM in my left ventricle. Encouraged by the confident demeanor of the surgeon and his impressive credentials, I agreed to the full-Monty. (I was also told that the doctors would attempt to ablate my A-fib "while they were in there.") The entire procedure took 6 1/2 hours and I spend 2-3 days in IC for recovery (a horrible experience). The bill came to more than half-a-million dollars, which (thank goodness!) Medicare paid. Fast forward to the summer of 2022 when I was experiencing myocarditis-like symptoms after taking the Covid vax (an "impossible" connection my cardiologist stated, given my 70+ age and the "fact" that vax-induced myocarditis only affects young men). Insisting on further examination, my doc complied by ordering arthroscopy which discovered a couple of interesting situations. First, the heart muscle of my apex was found to be necrotic (dead) and therefore not pulsing to improve the volume of blood/circulation from my left ventricle, as the myectomy had intended. Second, the scan showed that the 2014 LAD bypass had completely failed and that the blood flow was traveling through the original LAD (which, incidentally, now showed to be only 70% blocked -- not the 99% that the 2014 diagnosis stated) and was capably carrying the load during my current daily bouts of intense exercise). Finally, I awoke from my $500K+ surgery with a (surprise!) pacemaker, suggesting that perhaps the attempted ablations of my A-fib had been irreparably botched and therefore "covered" by the pacing device. Since my surgery, I began wondering how many other "life-saving" medical procedures have been performed on countless trusting patients solely to enrich the hospital and doctors involved? And if the old saying might actually be true that "doctors bury their mistakes." Over the recent decdes, we've herd about countless cases of needless stenting and bypass procedures performed on innocent patients who haven't been helped one iota by these practices. Furthermore, we've had no convincing scientific data that these procedures are life-saving or even helpful (except in the instances of an actual MI in progress). Performing unnecessary surgical procedures on unsuspecting patients should be a punishable crime -- and the physicians who profit should be treated like the criminals that they are. Indeed, the willful ignorance on the part of the entire practice of cardiology by condoning these practices and not actively seeking scientific proof of their efficacy should be called into public examination. When will there be a reckoning or justice? When will cardiology reform itself? When will individual practitioners "come clean?' Tragically, not in my lifetime, I dare say.