Bypass beats stents in diabetics & elderly

Heart disease occurs when fatty deposits (plaques) settle on the insides of the arteries and reduce or even completely stop the flow of blood, writes Sanchita Sharma.

Writing on health is a nightmare , mostly. A simple “How are you today?” can get you unexpected reactions. Some clam up thinking you want to drudge out their deepest, darkest medical secrets for an embarrassing expose, while others break into a litany of all the disorders they have suffered, ever. What’s more, they want answers, already.

Today, I’m happy to report that I finally have the answer to a question I am asked almost every week: which procedure is better to treat heart disease, bypass surgery or angioplasty?

Heart disease occurs when fatty deposits (plaques) settle on the insides of the arteries and reduce or even completely stop the flow of blood. While non-critical situations are treated using medicines and making lifestyle changes, life-threatening blockages need treatment.

Bypass surgery involves grafting one or more healthy vessels to the heart to bypass the blocked ones. On the other hand, angioplasty is a non-surgical procedure in which small wire-mesh metal tubes called stents are put inside the blocked artery to prop them open.

In a landmark study published in the April 4 issue of The Lancet, bypass surgery has emerged as the treatment of choice over stent implantation for heart disease involving multi-vessel blockages in patients who are older and those who have diabetes.

For the study, researchers led by Prof Mark A Hlatky from the Stanford University School of Medicine in the US analysed data of 7,812 patients from 10 existing studies around the world. The study found that while long-term risk of death was similar after bypass and stent implantation, bypass was a better option for patients with diabetes and patients aged 65 years or older because it lowered their risk of death.

The findings have relevance for India for many reasons. First, many Indians become insulin-resistant — a pre-diabetes condition — or develop diabetes after the age of 50 years. Second, Indians have smaller arteries and develop multi-vessel blockages — PM Manmohan Singh’s five blockages is an excellent example — that are more critical.

“Bypass is the preferred option as Indians tend to have blood vessel blockages that are multiple, long or positioned in the beginning of the artery. Indians also have smaller arteries, which increases the risk of restenosis — narrowing of the artery — completely restricting blood flow,” says cardiac surgeon Dr Naresh Trehan, chairman, Global Health.

The main limitation of angioplasty is the risk of scar tissue growth around the stent in the treated artery, leading to restenosis. Stents coated with medication prevent scar tissue growth and significantly reduce the risk of in-stent restenosis. With drug-coated stents bringing down restenosis to 7-8 per cent, angioplasty is done only if the blockages are in one or two non-critical arteries.

Apart from patient-specific characteristics, cost should also be factored in while choosing a procedure. The cost of about Rs 2 lakh makes bypass surgery safe and affordable for most people. With each drug-coated stent priced at about Rs 1 lakh, angioplasty, though less invasive, costs much more.

But then, recovery after angioplasty is faster, so ultimately, the patient is king.