Are bypass operations a big scam?

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bob@nospam.com - 19 Jan 2006 04:00 GMT

My jaw dropped when I read about this study below in the New England Journal
of Medicine (hardly some quack alternative medicine resource). Is this 1984
CASS study still authoritative or has it been debunked? From what I gather,
bypass operations HAVE been shown to be effective in the small minority of
patients who have a left main coronary artery blockage, but otherwise not.

What does this mean- if the cardiologist tells you that you need a bypass
operation and you don't have the left main artery blockage, should you
assume he's trying to scam you? Are there any other valid reasons to get a
bypass?

TIA,

Robert

N Engl J Med. 1984 Mar 22;310(12):750-8.

Myocardial infarction and mortality in the coronary artery surgery study
(CASS) randomized trial.

[No authors listed]

The long-term benefit of coronary bypass surgery in terms of longevity and
prevention of major ischemic events in patients who have mild angina is not
well defined. The randomized Coronary Artery Surgery Study (CASS) was
designed to evaluate this issue; it consists of 780 patients who were
considered operable and who had mild stable angina pectoris or who were free
of angina after infarction. As a result of the randomization process there
were no significant differences in base-line variables between patients
randomly assigned to medical and to surgical therapy. The likelihood of
death in the five-year period after randomization was only 8 per cent in the
medical cohort, as compared with 5 per cent in the surgical cohort (not
significant). The likelihood of nonfatal Q-wave myocardial infarction was 11
and 14 per cent, respectively (not significant). The five-year probability
of remaining alive and free of infarction was 82 per cent in the patients
assigned to medical therapy and 83 per cent in the patients assigned to
surgery (not significant). There were no statistically significant
differences in the survival rate or in the myocardial-infarction rate
between subgroups of patients randomly assigned to medical and to surgical t
herapy when they were analyzed according to initial group assignment, number
of diseased vessels, or ejection fraction. Therefore, as compared with
medical therapy, coronary bypass surgery appears neither to prolong life nor
to prevent myocardial infarction in patients who have mild angina or who are
asymptomatic after infarction in the five-year period after coronary
angiography,

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Andrew B. Chung, MD/PhD - 19 Jan 2006 06:00 GMT

> My jaw dropped when I read about this study below in the New England Journal
> of Medicine (hardly some quack alternative medicine resource). Is this 1984
[quoted text clipped - 5 lines]
> operation and you don't have the left main artery blockage, should you
> assume he's trying to scam you?

No.

> Are there any other valid reasons to get a
> bypass?

For relief of angina symptoms.

> TIA,
>
[quoted text clipped - 30 lines]
> asymptomatic after infarction in the five-year period after coronary
> angiography,

A non-invasive alternative to either bypass surgery or
angioplasting/stenting:

http://tinyurl.com/79ot6

Would be more than happy to "glow" and chat about this and other things
like cardiology, diabetes, cooking and nutrition that interest those
following this thread here during the next on-line chat (01/19/06) from
6 to 7 pm EST:

http://tinyurl.com/cpayh

For those who are put off by the signature, my advance apologies for
how the LORD has reshaped me:

http://tinyurl.com/bgfqt

Prayerfully in Christ's love,

Andrew
http://tinyurl.com/b6xwk

Reply to this Message

Sue - 21 Jan 2006 01:16 GMT

> > My jaw dropped when I read about this study below in the New England Journal
> > of Medicine (hardly some quack alternative medicine resource). Is this 1984
[quoted text clipped - 12 lines]
>
> For relief of angina symptoms.

> > TIA,
> >
[quoted text clipped - 52 lines]
> Andrew
> http://tinyurl.com/b6xwk

Dear Dr Chung (and other interested parties),

There are minimally invasive sugeries available today that eliminate
the need to be pout on bypass during surgery.

In many cases, we are now able to use an instrument that has "suction
cups," that provides local stabilization the heart tissue during
surgery. This allows the surgeon to operate on a beating heart. This
eliminates the need for cardioplegia (a solution applied to the heart,
that stops the heart); eliminates the need to be placed on a
cardiopulmonary bypass pump machine, and eliminates the need to restart
the heart (using defibrillation).

So overall, the procedural risks are greatly reduced. Granted, come
cardiac surgeons that have not used this technique & may not be
comfortble trying it (they prefer to work on a completely still heart).
Yet it appears that more and more surgeons are adopting this method
when possible.

Example:
http://www.hsforum.com/stories/articleReader$638

Sue (nondoctor, research/medical device company)

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Erskine James - 21 Jan 2006 04:09 GMT

Robert,

The cynical answer is that if a cardiologist refers a patient for
bypass rather than angioplasty, then that is really the truth, as that
is a procedure the cardiologist does not do. (And all cardiologist want
to do everything! :) ) Bypass prevents death in left main and
proximal LAD disease. It reduces angina in other areas. In older
studies (pre-drug eluting stents) was proven superior to angioplasty in
patients with left main disease, and patients with multiple coronary
disease and diabetics or patients with poor ejection fractions, to put
it simply.

Sue,
Off-pump or on-pump is not a cardiologist call--that is a surgeon call.
There is small data that shows offpump decreases cognitive decline
("pumphead" syndrome) but the overall cardiac outcome at 1 year is not
different between on or off pump. In addition there have been one or
two trials which showed increased graft occlusion at 3 months with
off-pump surgery. So I leave the decision of on-pump or off-pump to the
surgeon.

Reply to this Message

Erskine James - 21 Jan 2006 04:55 GMT

Robert,

Also, you may wish to go to the ACC website and look at the guidelines
for CABG. They are written for physicians, but are fairly
understandable to lay people as well.

http://www.acc.org/clinical/guidelines/cabg/index_pkt.pdf is the web
address for the pocket guidelines on CABG

Reply to this Message

Andrew B. Chung, MD/PhD - 21 Jan 2006 14:23 GMT

> Robert,
>
[quoted text clipped - 16 lines]
> off-pump surgery. So I leave the decision of on-pump or off-pump to the
> surgeon.

Would concur.

May the LORD help us all to face the great tribulation when the Lamb
opens the 6th seal possibly in less than a few months (03/29/06), in
Jesus' most precious and holy name.

Amen !!!

Now this is about the works of the four horsemen from the 6th chapter
of the Book of Revelation (we are now in the 6th year into the third
millenium after the birth of the Son of Man):

(1) Crowned rider wielding a bow and riding a white horse:

"See you on the other side. It's not bad. We are just going to
sleep." - missive (missile) from one of 12 born-again Christian miners
who gave up their lives to save the youngest among them after being
trapped by an explosion in a W.Va mine.

(2) Rider wielding a sword and riding a fiery red horse:

Ariel Sharon, the world's hope for lasting peace in the middle east,
suffers a massive bleeding stroke. Violence and bloodshed in Iraq
escalates. U.S. now less likely to pull out of Iraq anytime soon.

(3) Rider wielding a set of food scales and riding a black horse:

The rate of increase of the number of people worldwide using the
2PD-OMER Approach (which advocates the use of food scales) accelerates
with growing worldwide concerns about the obesity epidemic:

http://www.HeartMDPhD.com/wtloss.asp

Meanwhile, folks like Bob Pastorio who refuse to use this Approach are
heard muttering that an omer is not a weight measure but a volume
measure somewhere between one and three quarts depending on what the
food is and that liquid foods like milk (emulsified oil) and wine
should not be counted toward daily intake.

(4) Rider on a pale horse given the authority to kill a fourth of the
world's population "by sword, famine and plague, and by the wild beasts
of the earth":

The H5N1 Avian Flu Pandemic seems to be starting in Turkey:

http://tinyurl.com/amj4a

Yes, the migratory birds spreading H5N1 virus are wild beasts of the
earth.

When will the sun "turn black like sackcloth made of goat hair"
(Revelation 6:12b) ?

It will turn black during the total solar eclipse that will happen
**also** in Turkey on Wednesday 03/29/2006 at around 14:00 hrs LT.

http://tinyurl.com/dcj7w

The order of darkening of the following ancient cities in Turkey:

(1) Ephesus
(2) Smyrna
(3) Pergamum
(4) Thyatira
(5) Sardis
(6) Philadelphia
(7) Laodicea

Will be the same order that Christ Jesus used to address the seven
churches:

"Write on a scroll what you see and send it to the seven churches: to
Ephesus, Smyrna, Pergamum, Thyratira, Sardis, Philadelphia and
Laodicea." (Revelation 1:11)

Would be more than happy to "glow" and chat about this and other things
like cardiology, diabetes, cooking and nutrition that interest those
following this thread here during the next on-line chat (01/26/06) from
6 to 7 pm EST:

http://tinyurl.com/cpayh

For those who are put off by the signature, my advance apologies for
how the LORD has reshaped me:

http://tinyurl.com/bgfqt

Prayerfully in Christ's love,

Andrew
http://tinyurl.com/be9va

Reply to this Message

bob@nospam.com - 21 Jan 2006 14:29 GMT

Thanks to all for their info. It turns out we don't need to decide as my dad
finally went to the cardiologist and his thallium stress test was normal.
The assumption at this point is that his chest pain episode was gastric in
nature- perhaps an esophageal spasm or very bad heartburn.

Robert

Reply to this Message

Andrew B. Chung, MD/PhD - 21 Jan 2006 16:46 GMT

> Thanks to all for their info. It turns out we don't need to decide as my dad
> finally went to the cardiologist and his thallium stress test was normal.

Praise the LORD :-)

May the LORD help us all to face the great tribulation when the Lamb
opens the 6th seal possibly in less than a few months (03/29/06), in
Jesus' most precious and holy name.

Amen !!!

Now this is about the works of the four horsemen from the 6th chapter
of the Book of Revelation (we are now in the 6th year into the third
millenium after the birth of the Son of Man):

(1) Crowned rider wielding a bow and riding a white horse:

"See you on the other side. It's not bad. We are just going to
sleep." - missive (missile) from one of 12 born-again Christian miners
who gave up their lives to save the youngest among them after being
trapped by an explosion in a W.Va mine.

(2) Rider wielding a sword and riding a fiery red horse:

Ariel Sharon, the world's hope for lasting peace in the middle east,
suffers a massive bleeding stroke. Violence and bloodshed in Iraq
escalates. U.S. now less likely to pull out of Iraq anytime soon.

(3) Rider wielding a set of food scales and riding a black horse:

The rate of increase of the number of people worldwide using the
2PD-OMER Approach (which advocates the use of food scales) accelerates
with growing worldwide concerns about the obesity epidemic:

http://www.HeartMDPhD.com/wtloss.asp

Meanwhile, folks like Bob Pastorio who refuse to use this Approach are
heard muttering that an omer is not a weight measure but a volume
measure somewhere between one and three quarts depending on what the
food is and that liquid foods like milk (emulsified oil) and wine
should not be counted toward daily intake.

(4) Rider on a pale horse given the authority to kill a fourth of the
world's population "by sword, famine and plague, and by the wild beasts
of the earth":

The H5N1 Avian Flu Pandemic seems to be starting in Turkey:

http://tinyurl.com/amj4a

Yes, the migratory birds spreading H5N1 virus are wild beasts of the
earth.

When will the sun "turn black like sackcloth made of goat hair"
(Revelation 6:12b) ?

It will turn black during the total solar eclipse that will happen
**also** in Turkey on Wednesday 03/29/2006 at around 14:00 hrs LT.

http://tinyurl.com/dcj7w

The order of darkening of the following ancient cities in Turkey:

(1) Ephesus
(2) Smyrna
(3) Pergamum
(4) Thyatira
(5) Sardis
(6) Philadelphia
(7) Laodicea

Will be the same order that Christ Jesus used to address the seven
churches:

"Write on a scroll what you see and send it to the seven churches: to
Ephesus, Smyrna, Pergamum, Thyratira, Sardis, Philadelphia and
Laodicea." (Revelation 1:11)

Would be more than happy to "glow" and chat about this and other things
like cardiology, diabetes, cooking and nutrition that interest those
following this thread here during the next on-line chat (01/26/06) from
6 to 7 pm EST:

http://tinyurl.com/cpayh

For those who are put off by the signature, my advance apologies for
how the LORD has reshaped me:

http://tinyurl.com/bgfqt

Prayerfully in Christ's love,

Andrew
http://tinyurl.com/be9va

Reply to this Message

Sue - 23 Jan 2006 00:36 GMT

> Thanks to all for their info. It turns out we don't need to decide as my dad
> finally went to the cardiologist and his thallium stress test was normal.
> The assumption at this point is that his chest pain episode was gastric in
> nature- perhaps an esophageal spasm or very bad heartburn.
>
> Robert

Robert,

I am so happy to hear that this was a false alarm! I am also happy
that you played it safe and your dad was thoroughly checked out by
professionals.

People can overlook anginal symptoms that are heart -related. In these
cases, sometimes this can cost a person his/her life.

For instance, I had a friend that had jaw pain and went to the dentist
instead of his physician (thinking he had a tooth problem).

Two weeks later he had a massive heart attack. It was later
determined that his jaw pain was likely an overlooked warning sign.

Better to be safe, than sorry (IMHO).

Very Best wishes,

Sue (nondoctor)

Reply to this Message

Sue - 22 Jan 2006 18:49 GMT

> Robert,
>
[quoted text clipped - 16 lines]
> off-pump surgery. So I leave the decision of on-pump or off-pump to the
> surgeon.

"So I leave the decision of on-pump or off-pump to the surgeon."

Reply. Absolutely. Off-pump is not indicated in all cases. Also the
cardiologist does not have hierarchy when it comes to surgical
treatment decisions. The surgeon is in control. The cardiologist may
however refer a patient to one surgeon versus another surgeon.

>From my research experience in helping to bring various new

technologies to market (such as MICS-minimally invasive cardiac surgery
methods), I have realized that there is often slow acceptance among
some of the professionals.

This is a double edged sword. On one hand (as in this case) it shows
that cardiac surgeons are careful to accept newer techniques without
sufficient evidence in their own minds, that indicates improved
outcomes. Afterall, they bare the bulk of the responsibility and risks
associated with any new procedure. This is understandable.

However (and I realize this is a judgmental statement), there are some
surgeons that reject change simply because they are not comfortable
with change. I say this because we have heard this feedback by the
professionals within the medical profession itself!

For example, there are still some surgeons that choose on-pump,
regardless of circumstance, simply because they have not been trained
in off-pump surgery. They are more comfortable with what they know and
what they have been doing for years. And in some cases, the
institution may lack funding to incorporate new technology.

Hopefully the attending cardiologist can refer his/her patients to a
surgeon and insitution that considers all options. Only is this
manner can the best individual decisions be made, IMHO.

Sorry so longwinded, but meant in all seriousness. I am for increased
awareness and patient education.

Best wishes,

Sue (non doctor)

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