Do I need a heart operation?

THESE days, heart attacks are so treatable that many people, including doctors and patients alike, can become too complacent as to the dangers and potential lethal consequences of heart disease.

Many of us are becoming inured to the still very serious outcomes that we sometimes forget that heart attacks continue to kill some three out of every 10 Malaysians who die. An estimated 12,000 Malaysians still die of heart attacks every year, and some 280,000 Malaysians have ongoing coronary (or ischaemic) heart disease.

Depending on the situation, heart surgery is sometimes the best option for a patient.
Sadly too, some one-third or more of heart attack victims die very quickly without ever getting to a medical facility on time. Then, among those who do make it to a hospital, some 8 to 15% still succumb to the complications of a heart attack, no matter what expert therapies are offered.

Medical advances have helped improve heart attack survival. However, it is true that we now have a multitude of specialised treatments that can dramatically help heart attack patients – often limiting the damage and severity of the heart attack.

Health
Sunday June 24, 2007

Do I need a heart operation?

By DR DAVID KL QUEK

There are many measures that can be taken for heart disease – diet, lifestyle measures, drugs, surgery. Which works best?

THESE days, heart attacks are so treatable that many people, including doctors and patients alike, can become too complacent as to the dangers and potential lethal consequences of heart disease.

Many of us are becoming inured to the still very serious outcomes that we sometimes forget that heart attacks continue to kill some three out of every 10 Malaysians who die. An estimated 12,000 Malaysians still die of heart attacks every year, and some 280,000 Malaysians have ongoing coronary (or ischaemic) heart disease.

Depending on the situation, heart surgery is sometimes the best option for a patient.
Sadly too, some one-third or more of heart attack victims die very quickly without ever getting to a medical facility on time. Then, among those who do make it to a hospital, some 8 to 15% still succumb to the complications of a heart attack, no matter what expert therapies are offered.

Medical advances have helped improve heart attack survival. However, it is true that we now have a multitude of specialised treatments that can dramatically help heart attack patients – often limiting the damage and severity of the heart attack.

In the best scenarios, lives can be saved and complications such as heart failure drastically reduced.

Improved survival rates

Over the past 30 years or so, salvage rates for heart attack patients have increased significantly in most Western developed countries. Survival from heart attacks has improved some 30 to 50% in countries ranging from the United Kingdom to the United States, including Australia and New Zealand.

Why has survival from heart attacks improved these three decades? Has our medical treatment improved so much or is it due to the many technological advances such as bypass surgeries, angioplasties and stents?

In a recent review conducted by an American group of medical scientists, it is calculated that some 50% of the reduction in the risks of dying from heart attacks are due to better control and awareness of the many avoidable risk factors.

These include measures such as lowering blood pressure, lowering blood cholesterol, controlling diabetes, quitting smoking, and other public health measures such as better healthier dietary habits and physical conditioning such as exercise.

Thus, rigorous public health measures and individual behavioural changes in reducing these bad risks can contribute to lesser incidence of heart attacks, sudden death and even strokes (brain attacks).

Only about half the better outcome effects are due to the special therapies and advanced techniques of management such as better and safer medications, clot-busting drugs, coronary angioplasty, stenting or bypass surgery.

Clearly, when used early, appropriately and under expert hands, early re-opening of clogged blood vessels by mechanical means (such as angioplasty or surgery, termed revascularisation) can be life-saving – usually halving the rate of dying when compared with just using clot-busting drugs alone.

A recent Harvard University study led by Prof. Setoguchi, carefully reviewed some 21,848 patients (half of whom died over the 10 years of follow-up) over a period from 1995 to 2004.

The study found that the use of specially-tested drugs following a heart attack such as low-dose aspirin, beta-blockers, angiotensin-converting enzyme-inhibitors (ACE-inhibitors) or angiotensin receptor blockers (ARB), statins (to lower bad cholesterol) helped to lower the risk of dying by some 3% every year.

This reduction in dying rate comes over and above angioplasties, stents or bypass surgeries, which were usually performed within 30 days of the heart attacks.

So this brings us to the question of whether everyone diagnosed with coronary artery/heart disease or who have had a heart attack, should get some form of mechanical revascularisation; or, would simply taking medicines do?

Medications alone may be sufficient for some stable heart patients

There is currently some confusion, because lately a study known as COURAGE (Clinical Outcomes Utilizing Revascularisation and Aggressive Drug Evaluation), showed that taking a clutch of heart medicines appropriately can be as good as undergoing stent-angioplasty, for patients with the stable form of the disease.

Although this study appears contentious in the eyes of aggressive interventional cardiologists (sometimes labelled as “balloonists” or “stentists”), many other physicians are becoming drawn to the fact that perhaps, for too long, cardiologists have been too gung ho and too eager to impart their specially-honed skills of micro-surgical re-opening of heart arteries, without adequately having studied the implications or the techniques’ cost-effectiveness or ultimate benefits.

But whatever the misgivings, the evidence is quite provocative: Those who have stable heart disease, ie those who have relatively easy to control symptoms of angina (chest pains, discomfort or breathlessness brought on by exertion or stress) can be safely treated with medications.

More often than not, drugs such as statins are part and parcel of the treatment regimen for those with coronary heart disease. - AP
These people who do not suddenly progress with their symptoms can be treated for their risk factors comprehensively as well as with pain-relieving drugs which would lower their risk of dying or suffering complications of heart attacks, to an acceptable level.

What this means is that every patient should be looked at holistically. He or she should have all their risks assessed completely, and when these are present they should be treated aggressively to expert-guided targets.

Once this can be achieved, then the risks of heart events are similar to those who undergo stent-angioplasty.

One criticism of this study is that the type of stent used in this group of patients was the non-medicated type, and that this might have affected the outcome. This is however not necessarily so because drug-coated stents have their own problems as well, as I will discuss below.

Aggressive risk-factor control helps cut heart complications

Importantly, the patient with stable coronary disease should be treated for each and every of his/her risk factors, and to predetermined goals.

For example, if one has hypertension, then this should be treated to target levels of blood pressure less than 140/80. The physical stress on the heart and work needed to pump blood around the body is improved when blood pressure is adequately controlled.

Remember that untreated hypertension is the cause of kidney failure, enlarged poorly pumping hearts, strokes and heart attacks, and not the other way round. Medicines help ward off these complications.

If one has a smoking habit, then this should be stopped at once and for always. The noxious fumes and biochemical poisons (more than 3,000, including tars, carbon monoxide and nicotine) contained in tobacco smoke wreak havoc on the surface lining of the blood vessels, causing them to break down easily and allowing “bad” LDL cholesterol particles to seep into the walls to form plaques.

Blood vessel tone is also increased, and these poisons can crack the vessel inner surfaces, which then trigger blood clumping and clots, which in turn can cause heart attacks.

When the blood cholesterol level is raised, especially the “bad” LDL cholesterol, this should be suppressed by statins to appropriately low levels (usually less than 2.6 mmol/l or even lower, if your cardiologist feels it necessary).

This LDL is the main culprit that causes plugging and narrowing of blood vessels (with fatty clumps) anywhere in the body, but predominantly more so in heart and brain arteries.

If diabetic, the blood sugar should be lowered by stringent dietary control as well as medicines. The monitoring marker HbA1c (glycosylated haemoglobin), which measures good glucose control averaged over three to four months, should be less than 7% (normal people have HbA1c of between 3-5%).

Of course, dietary modifications and regular exercise programmes are also important to adhere to for better results following a heart attack, or anyone at risk of heart disease.

So, what does this mean for the heart patient? Does this mean that bypass surgeries or angioplasties are no longer necessary? Clearly not. Circumstances vary from patient to patient, and there is still that very important need, indeed critical need, for some form of revascularisation in many cases where the heart condition deteriorates or becomes unstable, ie when a heart attack is impending or threatening to strike.

However, in those with early disease or when symptoms are stable and can be easily controlled (this should be verified and assessed carefully by your doctor), medications taken attentively can be as good in preventing loss of life or health.

With the advent of self-referred CT heart scans, picking up non-significant heart artery narrowings is getting easier, but its significance remains unclear particularly among symptom-free worried-well people.

It is however becoming increasingly clear that not everyone who is found to have a narrowing in a heart vessel needs to have balloon or stent angioplasty (unless the clogged artery is causing symptoms which cannot be controlled easily with medicines). When in doubt it is probably prudent to seek a second opinion, preferably from another physician without a vested interest.

What many reasonable doctors now believe is that we should allow some time for medicines to help stabilise the condition – a good trial of medications alone is prudent and may be all that is necessary. It is also as safe and more cost-effective in many instances.

Who needs revascularisation?

While a trial of medicines may be prudent for some patients, others may need more drastic therapies such as angioplasties.

It is getting more evident that those whose heart symptoms escalate rapidly or worsen suddenly (called unstable angina, acute coronary syndrome, acute myocardial infraction), should be treated very urgently. In many cases, re-opening of the culprit clogged heart arteries may be life-saving and disease modifying, ie heart muscle damage is ameliorated to a minimum and heart function preserved, as quickly as possible.

Many studies have now confirmed that angioplasty with stents have a prominent role to play in this group of patients. When treated aggressively and early, these can stop a heart attack from happening, or when a heart attack has already taken place, limit its damaging effects.

Balloon angioplasty alone has been found to be associated with re-closure of the cracked-open plaques, and stents are tiny wire mesh scaffoldings which tether up these crushed plaques to keep the flow channel for the blood open.

However, being metallic, these stents tend to attract a scarring process (over a short period of time, usually within the first six months) which can lead to re-narrowing of the heart arteries, which then defeats the purpose of the procedure.

This setback led to the development of drug-coated stents, which have been proven to stunt and even obliterate the scarring process from taking place. These drug-eluting or medicated stents are more expensive, and in earlier studies show great promise – arterial re-narrowing is spectacularly prevented for up to four years.

Until recently, these medicated stents were thought to be a godsend, and there was a tremendous jump in their use, by cardiologists hoping to keep their patients’ heart arteries from re-clogging again. Alas we did not foresee another unexpected adverse outcome of these stents.

Because these drugs (delivered locally) block the scarring process, the wire mesh structures remain “naked” at the site of the propped-up blood vessel lining for a long time – beyond six months or so. In normal cracked vessel linings, the broken surface usually heals by being repaired very quickly with a single layer of smooth cells. This fails to take place uniformly with medicated stents, which unfortunately lead to easy clotting complications.

This was the crux of the debate that flourished in the past year or so – clotting complications can occur late (sometimes a few years after the stent-angioplasty), with sometimes very severe consequences, including massive heart attacks and sudden death! Having said this, these dire consequences are rare, occurring in less than one in a few thousand cases.

Because of this potential serious complication, medical authorities worldwide now recommend that all patients who have received the drug-coated stents should take a dual antiplatelet regimen (low-dose aspirin plus clopidogrel) for at least one year or indefinitely if possible.

The important message is that doctors and patients should consider the use of technology more cautiously, and refrain from too much eagerness and indiscriminate use of what may be very promising at first sight. We have to weigh the options and evidence more meticulously to offer better and safer care for the patient’s longer term interest, based on what evidence shows to be the case.

Sometimes this would mean having to be more patient and circumspect, while scientists work at clarifying the longer term benefits or risks, which can manifest late.

While pin-hole types of corrective surgical measures, such as angioplasties, are attractive concepts for both cardiologists and patients, we can sometimes get lost in the translation of what truly matters, what truly works in the longer term.

Doctors are therefore advised to rein in their zeal with all things contemporary and novel, and learn to consider the potential hazards which may lurk beneath the surface of early promising benefits.

At this point in time, we must not be distracted by the pin-hole nature of surgery and expect that these least traumatic procedures are best for every case (cosmetically perhaps, but this should not cloud the best judgement!). Patients must be made to understand that sometimes bypass surgery carries better outcomes and longer survival despite the initial more traumatic assault on the chest and body.

For example, it is now recognised over and over again that most diabetic patients, those with left main stem disease, diffuse multi-vessel coronary artery disease, or poor heart function, are usually better candidates for coronary artery bypass surgery.

Nonetheless, for the more stable heart patients, perhaps all they need are carefully selected medications which should be taken with due compliance and duty, with periodic but regular check-ups. Buying medicines from the friendly local pharmacy without prescription can be hazardous; it is also illegal, and could harm your health. Heart medicines need periodic tweaking and monitoring for its expected effects or otherwise. Heart patients need close monitoring and assessment by a physician, preferably your own family physician who should know you and your health best, and who would know when to refer when necessary.

Another myth among many a patient, is that once surgery has been performed, then he or she is cured. This is far from the truth. Like it or not, coronary heart disease (just like hypertension, diabetes or having high blood cholesterol levels) cannot simply go away just because of angioplasty or bypass surgery – the disease process continues lifelong.

Hence, it has to be treated in the long-term with medications that have been shown repeatedly to help prolong survival, and offer good quality of life. Drugs such as aspirin, statins, beta-blockers, ACE-inhibitors, ARBs should not be stopped arbitrarily, and must be monitored by your physician for the best benefits.

Our current crop of heart protective medicines is so good and safe now that one should not be too anxious of their purported side effects. The greatest side effect of these medicines is that of a longer life and healthier survival!
source:thestar.com.my