The surgery or stent decision is best made by physicians in several areas of expertise who work together to review each patient’s traits, say Drs. David Hillis and Richard Lange, authors of two recent editorials in the New England Journal of Medicine. However, health care economics in this country push patients to leave the hospital quickly, putting the crunch on decision making.
SAN ANTONIO (May 28, 2009) — Whether a patient should have coronary-artery bypass surgery or stents depends on many factors and, in the majority of cases, should not be decided until a team of medical professionals has weighed in on the patient’s data.
Those are the insights of L. David Hillis, M.D., and Richard Lange, M.D., M.B.A., faculty cardiologists at The University of Texas Health Science Center at San Antonio who authored two invited editorials on coronary research studies this year for the New England Journal of Medicine. Dr. Hillis is a member of the journal’s editorial board.
“Therapy ideally is tailored to the patient, to clinical facts and to what the patient’s arteries look like,” Dr. Hillis said. “But one of the downsides of the way medical care is paid for in this country is we have a huge push to do things as quickly as possible, to shorten the length of stay in hospitals.”
This may lead to the tendency, once artery blockages are seen on an angiogram, to perform balloon angioplasty with stents right away rather than waiting for further evaluation, including assessment of lung problems and other disease states, Dr. Hillis said.
The team method is different. Cardiac surgeons, who perform bypasses, are best qualified to tell how the patient may respond based on his or her own heart and blood vessel architecture. Interventional cardiologists, who perform stent procedures, are best qualified to say whether a stent can be placed in an artery. “The whole team approach is more thoughtful,” Dr. Lange said.
Dr. Hillis is professor and chairman of the Department of Medicine in the Health Science Center’s School of Medicine. He occupies the Dan F. Parman Distinguished Chair in Medicine. Dr. Lange is executive vice chair of medicine and occupies the L. David Hillis, M.D. Endowed Chair in Medicine.
Excerpted highlights of their editorials:
• Coronary-artery bypass grafting (CABG), a type of surgery introduced in 1968, was the first method of coronary revascularization, which is the restoration of proper blood flow to the heart.
• Percutaneous coronary intervention (PCI) procedures began in 1977 with the first balloon angioplasty to open clogged arteries. In the 1990s, PCI was improved through the introduction of bare-metal stents, which are small wire-mesh tubes that hold vessels open. The Palmaz Stent, developed at the UT Health Science Center at San Antonio, was the first of these stents.
• Drug-eluting stents were approved for use in Europe and North America by 2000.
• In the U.S. in 2006, four times as many PCI procedures were performed than CABG procedures. The figures were 1.1 million PCI procedures versus 253,000 CABG procedures.
• In each patient, all pertinent clinical data should be reviewed by a “heart team” consisting of a cardiac surgeon and an interventional cardiologist. Together, they will best determine the likelihood of safe and effective coronary revascularization with PCI and CABG.
• To ensure a thorough review, neither procedure should be performed at the time of diagnostic angiography. The heart team must have time to review all data, reach a consensus and discuss the findings with the patient.
• Patients with acute coronary syndromes, which include some cases of chest pain and heart attacks, can be divided into high- and low-risk groups based on algorithms that indicate which patients are most at risk for a subsequent cardiac event or treatment-related complication. This can guide therapy decisions.
• In most cases, angiography to detect abnormalities may be safely delayed for several days to allow medical therapy to stabilize the patient, thereby reducing the risk of procedure-related complications. Treatment depends on the patient’s level of risk for a subsequent cardiac event.
The editorials are available as PDFs from the UT Health Science Center Office of External Affairs or at these links: http://content.nejm.org/cgi/content/short/360/10/1024 and http://content.nejm.org/cgi/content/short/360/21/2237.
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