For those contemplating open-heart surgery, specifically coronary bypass surgery or CABG, this anesthesiologist's detailed description of his experience is a must read
Very interesting collection of thoughts and experience thank you. As a primary care doc I defer to cardiologist and cardiothoracic expertise on CABG vs PTCI for sure… but I thought that in several situations, CABG has been proven superior? Please don’t waste your time with what could be a really long answer, but does this answer from Claude sound about right to you, too?
“Yes, there is evidence for a mortality benefit with CABG (Coronary Artery Bypass Grafting) compared to PTCA (Percutaneous Transluminal Coronary Angioplasty)/PCI in specific patient populations. Here are the key findings:
1. Left Main Disease and Multivessel Disease:
- CABG shows superior survival in patients with left main coronary artery disease
- Better outcomes with CABG in patients with 3-vessel disease, especially with reduced left ventricular function
- The SYNTAX trial demonstrated better outcomes with CABG in patients with complex coronary anatomy (high SYNTAX scores)
2. Diabetic Patients:
- The FREEDOM trial showed clear mortality benefit with CABG in diabetic patients with multivessel disease
- At 5 years, CABG showed lower rates of death and MI compared to PCI
3. Long-term Outcomes:
- CABG generally shows better long-term freedom from repeat revascularization
- Lower rates of major adverse cardiac events (MACE) in the long term with CABG
However, PCI may be preferred in certain situations:
It is likely above my pay grade to argue with Claude but I will say that this is a complicated, evolving area in cardiology.
If we accept that the two cases mentioned in my piece (my dad and the anesthesiologist) were examples of stable coronary artery disease (i.e. not acute coronary syndrome or acute MI) then we have much evidence from recent trials that medical management is as good as revascularization even when ischemia is present.
The older trials establishing CABG as superior to med therapy took place prior to widespread use of statin and other disease modifying therapy we now consider optimal.
As to PCI vs CABG, much depends on the subjective qualitative assessment of %stenosis by operators in clinical practice, PCI long term outcomes have Improved since first generation DES, and trials show varying results.
Whatever path a patient chooses, it is best that they understand all of the myriad potential complications of the options presented and I think "Getting Better" describes some very common ones that should be considered if CABG is chosen.
Thank you! You've written this before, but I also find this mantra of yours very helpful:
"...examples of stable coronary artery disease (i.e. not acute coronary syndrome or acute MI) then we have much evidence from recent trials that medical management is as good as revascularization even when ischemia is present."
Being an RN in cardiac step down units, then having an MI and subsequent quadruple bypass at the age of 46, this article has surely peaked my interest. My surgery was in 2008. I had no history of CAD in my family, I was not overweight and had a normal total cholesterol and no hypertension. I was a light smoker on and off for over 20 years prior to my heart attack. I was no longer a cardiac nurse and was completely out of touch with new testing and treatments. I was old school and thought they still used CPKs and MB bands as an indicator of heart damage, never heard of triponin levels. I also never heard of the "beating heart" procedure which was done, nor did I ever see a radial artery used as a donor graft site! But the one thing that emerged since my surgery, was the Lp (a) test. My seriously abnormal result ( normal is <75, mine was 350) gave me some answers to why I developed heart disease at such a young age with no family history and risk factors except smoking. My younger sister had her Lp (a) tested after hearing of my result and discovered that both she AND her 17 year old daughter had Lp(a) levels so high, they weren't assigned an actual number! (Not sure how laboratories in Texas differ from Missouri in reporting results). We are all on statins now as well as medications for HTN. Their cholesterol levels were high as well. While my total cholesterol was always under 200, my LDL was always on the high side but was never addressed by my PCP as I had few other risk factors.
I was shocked at how CAD testing and treatment had changed since the days of my cardiac nursing in the late 80s to early 90s to 2008 when I was not able to recognize my own symptoms of cardiac disease and failed to address risk factors that led to my MI.
Very interesting read. And a useful idea by this anaesthesiologist. It is easy to, and I often do, forget about the details of a patient journey. And to appreciate that the specifics of a consent discussion regarding complications do and will occur for some/many patients. POAF being a particularly troubling one since we have little guidance (via data) for the best treatment strategy.
The Cardiology Trials substack is in the midst of reviewing studies pertinent to the scenarios discussed here. I agree the approach from the early aughts has less relevance today, esp for someone with MVD with normal LV function and who is not diabetic, and who did not present with MI.
I confess, I was a statin resistant otherwise healthy, Athletic, good eating emergency Physician. Same rationale of trying to eat right and exercise my way out of risk. Because of The skeptical cardiologist, I obtained a CAC study, which was higher than I wanted to see 212 with a bit of focus on the LAD) and with this finally overcame my reluctance to statins.
I find stain resistance to be mind boggling. Especially with patients who have diabetes. Same with other meds to treat the diabetes itself. I wish we were having more conversations on how to overcome this. We need some good poly pills. May a combo with 5 mg of tadalafil for gentlemen. Not sure about the ladies.
The other clear message is that one of the best weapons for prevention of CAD is a good PCP. however the pace we need to practice at is not conducive to conversation often required for statin initiation. And could someone please stop the “therapy gap” letters from insurers? They are barking up the wrong tree. I would say this is another arena where our public health system does a poor job. Health education overall is abysmal.
I don’t see the topic addressed on Social Media either. At least my channels. If I am missing something please let me know!
Very interesting collection of thoughts and experience thank you. As a primary care doc I defer to cardiologist and cardiothoracic expertise on CABG vs PTCI for sure… but I thought that in several situations, CABG has been proven superior? Please don’t waste your time with what could be a really long answer, but does this answer from Claude sound about right to you, too?
“Yes, there is evidence for a mortality benefit with CABG (Coronary Artery Bypass Grafting) compared to PTCA (Percutaneous Transluminal Coronary Angioplasty)/PCI in specific patient populations. Here are the key findings:
1. Left Main Disease and Multivessel Disease:
- CABG shows superior survival in patients with left main coronary artery disease
- Better outcomes with CABG in patients with 3-vessel disease, especially with reduced left ventricular function
- The SYNTAX trial demonstrated better outcomes with CABG in patients with complex coronary anatomy (high SYNTAX scores)
2. Diabetic Patients:
- The FREEDOM trial showed clear mortality benefit with CABG in diabetic patients with multivessel disease
- At 5 years, CABG showed lower rates of death and MI compared to PCI
3. Long-term Outcomes:
- CABG generally shows better long-term freedom from repeat revascularization
- Lower rates of major adverse cardiac events (MACE) in the long term with CABG
However, PCI may be preferred in certain situations:
- Single vessel disease
- Lower complexity lesions
- Higher surgical risk patients
- Acute coronary syndromes requiring immediate intervention
- Patient preference for less invasive approach”
It is likely above my pay grade to argue with Claude but I will say that this is a complicated, evolving area in cardiology.
If we accept that the two cases mentioned in my piece (my dad and the anesthesiologist) were examples of stable coronary artery disease (i.e. not acute coronary syndrome or acute MI) then we have much evidence from recent trials that medical management is as good as revascularization even when ischemia is present.
The older trials establishing CABG as superior to med therapy took place prior to widespread use of statin and other disease modifying therapy we now consider optimal.
As to PCI vs CABG, much depends on the subjective qualitative assessment of %stenosis by operators in clinical practice, PCI long term outcomes have Improved since first generation DES, and trials show varying results.
Whatever path a patient chooses, it is best that they understand all of the myriad potential complications of the options presented and I think "Getting Better" describes some very common ones that should be considered if CABG is chosen.
Thank you! You've written this before, but I also find this mantra of yours very helpful:
"...examples of stable coronary artery disease (i.e. not acute coronary syndrome or acute MI) then we have much evidence from recent trials that medical management is as good as revascularization even when ischemia is present."
Being an RN in cardiac step down units, then having an MI and subsequent quadruple bypass at the age of 46, this article has surely peaked my interest. My surgery was in 2008. I had no history of CAD in my family, I was not overweight and had a normal total cholesterol and no hypertension. I was a light smoker on and off for over 20 years prior to my heart attack. I was no longer a cardiac nurse and was completely out of touch with new testing and treatments. I was old school and thought they still used CPKs and MB bands as an indicator of heart damage, never heard of triponin levels. I also never heard of the "beating heart" procedure which was done, nor did I ever see a radial artery used as a donor graft site! But the one thing that emerged since my surgery, was the Lp (a) test. My seriously abnormal result ( normal is <75, mine was 350) gave me some answers to why I developed heart disease at such a young age with no family history and risk factors except smoking. My younger sister had her Lp (a) tested after hearing of my result and discovered that both she AND her 17 year old daughter had Lp(a) levels so high, they weren't assigned an actual number! (Not sure how laboratories in Texas differ from Missouri in reporting results). We are all on statins now as well as medications for HTN. Their cholesterol levels were high as well. While my total cholesterol was always under 200, my LDL was always on the high side but was never addressed by my PCP as I had few other risk factors.
I was shocked at how CAD testing and treatment had changed since the days of my cardiac nursing in the late 80s to early 90s to 2008 when I was not able to recognize my own symptoms of cardiac disease and failed to address risk factors that led to my MI.
Christine,
Good to hear from you! And thanks for sharing your remarkable story.
Very interesting read. And a useful idea by this anaesthesiologist. It is easy to, and I often do, forget about the details of a patient journey. And to appreciate that the specifics of a consent discussion regarding complications do and will occur for some/many patients. POAF being a particularly troubling one since we have little guidance (via data) for the best treatment strategy.
The Cardiology Trials substack is in the midst of reviewing studies pertinent to the scenarios discussed here. I agree the approach from the early aughts has less relevance today, esp for someone with MVD with normal LV function and who is not diabetic, and who did not present with MI.
I confess, I was a statin resistant otherwise healthy, Athletic, good eating emergency Physician. Same rationale of trying to eat right and exercise my way out of risk. Because of The skeptical cardiologist, I obtained a CAC study, which was higher than I wanted to see 212 with a bit of focus on the LAD) and with this finally overcame my reluctance to statins.
Good read. Thanks for taking the time . Please keep reading & writing.
Thanks. Interesting
I find stain resistance to be mind boggling. Especially with patients who have diabetes. Same with other meds to treat the diabetes itself. I wish we were having more conversations on how to overcome this. We need some good poly pills. May a combo with 5 mg of tadalafil for gentlemen. Not sure about the ladies.
The other clear message is that one of the best weapons for prevention of CAD is a good PCP. however the pace we need to practice at is not conducive to conversation often required for statin initiation. And could someone please stop the “therapy gap” letters from insurers? They are barking up the wrong tree. I would say this is another arena where our public health system does a poor job. Health education overall is abysmal.
I don’t see the topic addressed on Social Media either. At least my channels. If I am missing something please let me know!
My wife really hates stains. Especially the ones I create on nice couches.
But seriously, statin resistance is the norm here in SoCal where people prefer”natural” remedies and quacks abound.
Great idea on the male polypill!