Bypass Surgery, Angioplasty or Medicines only ?
Well , Let’s Call the Third Umpire !
Many times, when I advise coronary angiography to a patient,
one of the first questions posed by an anxious relative is: “After the
angiogram will we have to be ready to undergo angioplasty immediately ?”
My usual answer is ‘NO’ if the patient is clinically stable
and the disease not critical.
This answer is now vindicated by guidelines from various
cardiology bodies as will be seen below.
The field of cardiovascular medicine has seen great advances
and at the same time burdened us with a wide variety of choices. On the one
hand, the disease has become more and more complex with advanced age and
associated conditions, with widely different expectations from patients (for
example between a 91 year old and a 40 year old ) and widely different socio
economic backgrounds, and on the other, an explosion of scientific information
on newer and newer strategies of treatment.
Like the game of cricket, in some circumstances, the decision
or choice is straightforward, for example, a patient with acute coronary
syndrome (acute coronary problem-say, a heart attack) with an isolated single
discrete narrowing of an artery, in whom angioplasty with stent implantation
can be considered the treatment of choice with little or no disagreement, or a
patient with significant angina, multiple coronary occlusions, and other severe
complex disease in whom surgical revascularization is the treatment of choice.
Many patients, however, fit between these two extremes, and
in this continuum, multiple considerations exist.
What method of treatment is
best for such a patient ? A plethora of knowledge has accumulated about
the relative merits of angioplasty versus surgical treatment versus “optimal
medical therapy” alone, for such patients, and a potential danger exists of
individual physician biases and ‘forcing’ one method of treatment.
That is the time, which is very often, that a third ‘umpire’
- A HEART TEAM is needed.
This multidisciplinary team, including an experienced
cardiac surgeon, interventional cardiologist, and primary
cardiologist/physician, working together with the present state of knowledge,
as well as their individual experience can help to focus on specific patient
considerations and fully inform the patient and family about the risks/benefits
ratio of the various methods of treatment and help make choices.
By exploring the multiple options available and sharing them
with patients and their families where applicable, more optimal shared decision
making is achieved, along with a tailored recommendation for therapy for a more
informed and engaged patient. The goal is that the patient and family be
sufficiently educated about the alternatives available so that the best form of
treatment can be selected rather than 'forcing' a method of treatment.
This team-based care –the ‘Heart Team Approach’ has now been
strongly advocated by guidelines from various bodies such as the
European Society of Cardiology and the European Association for Cardio-Thoracic
Surgery as well as American College of Cardiology and the American
Heart Association.
Thus, whenever after a diagnostic angiogram, if the disease
found is more complex than can be addressed easily in a straightforward manner
or a potential exists for alternative methods of treatment such as angioplasty
versus surgical treatment versus “optimal medical therapy” alone, the patient
is taken off the table and the case discussed by the heart team followed by a
discussion of the merits demerits of the various modalities of treatment with
the patient and relatives.
Of course, the above recommendation is mainly for
stable patients whose condition may allow deferred decision making after the
heart team meets and deliberates. For most acute, unstable or emergency
patients the condition may not allow deferment of decision, which may have to
be taken fast (within minutes) in the best interests of the patient. Thus in
such patients ad-hoc angioplasty is the route usually recommended but rarely,
emergency surgery.
Also, another point to remember is that both surgery and
angioplasty do not exclude taking medicines. Modern cardiac medicines are the
fundamental and integral part of all modalities of treatment, one of them being
ONLY medicines.
While the age old adage ‘too many cooks spoil the broth’
does not apply here, ‘three heads are better than one’ applies very well – in Cricket
and in Cardiology.
- Dr Akshay Mehta
