Bypass vs Medical management

[CKA]

I have atypical angina for past 6 months. Burning in mid chest and left side off and on, lasting minutes to up to 2 hrs. However, this is NEVER releived by nitroglycerine. Pain is at rest and not with exertion.  Had stress thallium test-completely normal. EKG's during discomfort completely normal. Finally had cath- shows triple vessel disease. 60-70% in circumflex and R coronary, and 60% in LAD. Distal LAD is 90% and doctor says this part can't be bypassed. My doctor recommends bypass as soon as possible.  My Question: Is there a survival benefit with bypass surgery in this situation or is this only for symptom relief.  Symptoms are NOT disabling, but I am worried it may be angina although atypical.  Also, if no symptoms were present, would bypass be necessary just based on anatomy. I am afraid of surgery and want it done only if absolutely necessary. I am on full medical management. Thanks for your input.

[CCF-M.D.-CRC]

Dear CK,
Firstly I am very suspect of "angina" that is not brought on with exertion and is not relieved by nitroglycerine. There are other things that could be causing your pain including gastric reflux.  So the first thing is to exclude other possible causes of your symptoms.  

Concerning the benefits of surgery you are correct that the major benefit is symptom relief.  There is also an improvement in survival in those patients with low ejection fractions, those with diabetes and 3-vessel disease and in those with left main trunk stenosis.  There may be an very slight improvement in mortality in other patients with 3 vessel disease but this is not clear.  So in general I would say your concerns are not unfounded and you may want to discuss these issues with your doctor before proceeding.

[No Bypass / No Stents]

You didn't say what your lipid readings were, but if they are high, they should be treated.  A low HDL reading is probably the best indicator or risk for coronary artery disease.

I have a very bad situation, with a totally occluded RCA, about a 90% ostial occlusion of the circumflex, and a "cratered" plaque in my left main, which seems to block about 70% of that artery.

I have chosen not to have bypass, even though the attending cardiologist at my last aborted angioplasty warned me that I had a 40% chance of sudden death within 5 years if I didn't have the surgery.

Bypass surgery is a very traumatic procedure, with many long lasting side effects, and doesn't stop the disease process, especially where it is diffuse, as in your case.  Once done, it can't be undone.  The natural flow of blood through your coronary arteries is disrupted, and their is no chance for ever healing those arteries again.  The veinous bypass graphs that they use, have no naturaly endothelial response, and have a lifespan averaging 7 years.  Some people are hosed up after only a few years, some last 15 or 20 years, but sooner or later they all hit the end of their rope.

My belief is that coronary artery disease can be reversed with the proper medication and exercise.  Recent studies published by the University of Washington bear that out.  

Dual cholesterol therapy with Niaspan and a low dose of a statin (I think Lipitor is best of breed)  with a couple of daily 30 minute walks, will stop and probably reverse your disease over a couple of years.  Remember that it took 30 years to walk into the woods, so you have to have patience that it will take at least a few years to walk out.

I use a Lipitor + Welcol + Niaspan combination, which has given me a little regression in my disease, and , I believe, drastically lowered my risk of future heart attack.  I also use the ACE inhibitor, Altace, which I believe has effects beyond BP control.

The other most important thing that I do is walk.  I walk at least 30 minutes before work each morning and before lunch religously - rain or shine.  I walk a hilly circuit, which really get's the blood pumping.  On the weekends I do something more challenging.  This last weekend I cross country skied both days.  In the summer, I hike and climb.

As far as Angina goes, you can get a lot of aches and pains from stress and sitting around.  Get out and walk uphill.  If you get a strong ache in your breastbone, that's classic angina.  I push up against it every day, but never through it.  I have built up to a very high capability without having angina.

Exercising into or through real angina is counterproductive, however.  In my experience, it causes myocardial inflammation, which is a setback to recovery.

Also, my advice is to get off of all blood thinners (except aspirin), beta blockers, and nitrates.  Blood thinners are counterproductive to true endothelial health.  Beta blockers, work against your autonomic system - walking can better lower your heart rate.  Nitrates decondition your endothelial response to stress.

There are other aspects of my program, such as supplements, diet and, and daily attitude adjustment.  The main thing about diet is to get the meat, dairy, and saturated fat out as much as possible.  Take at least folic acid and a good mult-vitamin.  For attitude, now that you are going to live, what are you going to live for?  Is your life worthwhile or are you just taking up space?  I don't really think that I deserve to live these bonus years, if I can't find joy and happiness, and do something positive here.  I'm still working on that.

Good Luck

[jerry78]

No Bypass/No Stents:  Can you e-mail me at
***@****'d like to chat about heart health.  JERRY

[nurse12hr]

I am curious--what is your take on antihypertensives?  I am female, vegan, have great lipid profile, yet have developed mild hypertension (130's/mid80's at home, 150's/mid90's at work).  Not overweight, nonsmoker/nondrinker.  I have also started being worked up for what my doc and I suspect is angina, though this work has just started and I don't know for sure, but the pain seems classic.    
Just curious b/c I like your comments about diet/exercise.  Problem is, I already do those things.  
Thanks!

[No Bypass / No Stents]

Hi Cristie,

My only experience is with my own coronary artery disease and trying to stop and possibly reverse it.

I am a believer in the class of BP drugs called ACE inhibitors.  There have been several published studies indicating their use n people with CAD and heart failure.  I currently take a low dose of Altace, which seems to be a good drug with no side effects in my case.

My BP was borderline, but started getting up around 160 over 100.  I'm usually around 120/78 when I measure it now.  I do also take a low dose of the calcium channel blocker, Norvasc; however.

I would say that it's better to treat even borderline BP medically than to leave it go.

You can get a lot of different aches and pains in your chest from stress, but angina is pretty consistent with exercise.  I feel it as an ache in my sternum if I eat and then go out and do something like walk up a steep hill without a warmup.

Best Regards

[jallen]

I have been on many heart bypass sites but have just found this one and it is certainly the best so far.

I really admire your attitude and determanation, NoBypass.   I just hope you are making the right decision to not have any treatment other than medications.

Here is my story.   I am 6lf, had my first heart attack Thanksgiving 2000 (Canadian T/G that is) was visiting my son East of Toronto at the time.   After being stabilized I was air lifted to London, the best heart treatments in Ont. I believe.  But after several tests, no more symptems, signing up for a study called 'COURAGE' (which was Early Angioplasty + Meds vs Meds)   I was told I was too healthy to even participate in the study, even though I thought my angiogram indicated that I should at least have angioplasty.   On Dec. 30th 2000 I was admitted to hospital where I live with what the doctor diagnosed as "a touch' of Conjestive Heart Failure.   After five days I was shipped back to London, waited another week while they decided what to do, then had quintouple bypass.   I had an excellent surgeon but he ran into problems because three of the arteries he cleared were on the back of the heart, which couldn't have been done with angioplasty.   I spent 5 days in ICU and it has been a long haul but I think I am getting there.   I often wonder if I will ever feel normal again!

Now I am going to open up a completely different 'can of worms'. While I was in hospital the first time, I had to cancel an appointment I had with a doctor for a consultation on Chelation Therepy.   I have a strong family history of heart disease and my twin sister had her first angioplasty about seven years ago.   Had three altogether but thank God seems to be doing okay at the moment.   So I was going to see about the Chelation Therepy as a preventative measure.   I still intend on inquiring about it.   I think the only way it can hurt me is financially, because it is quite expensive.

It was a year ago on Friday (11th) since I had my surgery and I had to go to see the surgeon on Friday.   I didn't even mention to him about the Chelation Therepy.   I know for a fact that the doctor I am going to see won't do it if he doesn't think it will help you.

I would love to think that I could reverse artery disease with excercise and diet.  I do stick to a good diet and walk as much as possible but of course I have to avoid walking in cold temps as I have already had a heart attack.

I should mention that I never did feel very good after the heart attack but am feeling much better since the surgery.

Do you think that an angiogram is the only test that can tell the true story regarding blockages?   It is a pity that due to the high cost of performing them, they only seem to be done as a last result.

Anyone out there, please let me know what you think about Chelation Therepy.   I think the Doctors who take the time to answer questions on here are marvelous, but I doubt is I will get their blessing in this regard.

I do hope you keep a regular check on your conditions, NoBypass.

Thanks for listening,
jallen.