There is no one treatment guaranteed to be effective for all cases of coronary artery disease. But because there are different treatment options, it is important for every patient to have the information and resources necessary, after talking with a variety of healthcare professionals, to make informed decisions.
To determine the recommended form of treatment, physicians must first consider the extent of the problem. For those who have multivessel or left main coronary artery disease, surgery, not percutaneous intervention (PCI or Angioplasty) or stents, offers the best long-range outcome, according to David Taggart, MD, Professor of Cardiovascular Surgery at England’s University of Oxford.
Dr. Taggart, who has criticized the increasing trend to treat all patients with PCI or angioplasty without offering a surgical option, showed flaws in 15 trials of angioplasty versus surgery. Dr. Taggert believes that for the studies, low risk patients were used, whose outcomes would be excellent with any treatment.
“For these studies, 176,250 people were screened to find the ideal patients, and 95 percent of those screened were excluded,” Taggart said. “None of the patients in the trial had left main disease. Patients do want less invasive treatment, assuming the results are the same. But that is definitely not the case here.”
Dr. Taggart believes that part of the problem involves those who are responsible for decision making with patients. He said that when patients are informed of possible heart problems, their research should extend beyond a visit to a cardiologist.
“Failure to discuss CABG (coronary artery bypass grafting) means that the patient is often denied the best treatment option,” Taggert said. “Consent for PCI is often obtained inappropriately. Doctors are obligated to explain alternate options if they are more effective. Usually, the cardiologist is the gatekeeper, and there is a conflict of self-interest there, it is a self-referral. All patients with multivessel disease should be treated by a multidisciplinary team, including a surgeon.”
Taggert said that CABG is a remarkably safe and effective procedure, and has a good, long range prognosis.
Studies have also shed light on the merits of CABG over PCI under appropriate conditions. For example, a study published 2005 in the New England Journal of Medicine concluded that for patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting. That study showed that patients with three blocked arties who received stents were 56 percent more likely to die within three years as those who had bypass surgery. That study was addressed in a Wall Street Journal article which said that stenting, the popular, minimally invasive angioplasty procedure, carries a higher risk of death long term than does open heart bypass surgery as a treatment for blocked arteries. The Journal reported that more than a third of patients who received stents needed either surgery or additional angioplasties with stents within three years.