stents vs bypass

[SD2010]

I have diagnosed with CAD. I had one stent put in due to 99% occlusion. I need two more due to a 75% and 85% blockage. I just found out that I can either have two stents put in or have a bypass. The Dr. says it is my choice. Both have pros and cons. Since I am not a medical Dr. I have no idea which one to choose. I would prefer to take the option that has the best chance to last the longest and enable me to resume regular activities. I am 53, non smoker and was in good athletic condition. Suggestions?

[kenkeith]

If I got headaches or other side of effects from a nitrate or if there is no  relief from chest pains, I would go for stent implants.  Both dilate coronary vessels for better blood flow.

[ed34]

That's why I'm worried about having those nitro patches. I used to give a quick squirt of nitro under my tongue when I felt chest pains (as instructed by cardiologist) and I didn't get the dull headache most people get, mine was a really severe migraine type. I would go very light headed, too dizzy to stand up for at least 30 mins and felt nauseous. The odd thing is that the Nitro never relieved any symptoms at all. I personally believe that this was due to a total blockage at the top of the LAD and the distal section being fed by a few tiny collaterals. There was really no way to get the Nitro into the LAD effectively.
I think it odd that my medical records state "intolerant to Nitro" and yet they now want me to wear patches. My GP also prescribed me Nicorandil at one time saying "I give these to 80 year old ladies, 30mg a day. I want you to take 10mg and see how you get on". I got home, sat at the kitchen table and swallowed one. Within a few seconds the kitchen was spinning around at warp 7 and I was holding on tightly to the chair. Those old ladies are welcome to Nicorandil.

[Flycaster305]

I think, kenkeith and ed, we all agree, but come from different directions.  In my case, the decision to stent or have bypass was needed quickly as MI's were always involved.  Since getting a pacemaker, I've been on very aggressive drug therapy, but I'm starting to get some angina.  I have two 65% blocks in the LAD that are being watched as well as blockages in small vessels that can't receive stents.  That brings me to Nitrates... I take the generic form of Imdur which releases it 24/7 slowly.  I'm guessing the body develops a tolerance to it... to wit, when I first started taking it a small glass of wine would give me a nasty headache, and now that doesn't happen.  However, if I get angina strong enough to need a squirt of Nitrolingua, I get a headache quickly.  

[kenkeith]

That"s a good question, and I understand where you are going with the question, but the medical treatment for angina is usually a nitrate that specifically dilates the coronary vessels.  My understanding of nitrate medication one can develop a tolerance with continued useage without an interuption. I only take a nitrate 3 times a week without any problems so I can't verify by personal experience.

If and when the recommended dose for a nitrate is no longer effective, then intervention would be the only option.

[ed34]

Yes of course I totally agree, if symptoms can be controlled well enough through medication alone, then this is without a shadow of doubt the best option. However, one thing has puzzled me for quite some time. Is there a limit at which you have to say, enough is enough. For example, Mr X goes to Cardiologist and is prescribed medication A,B,C and D all at 20mg. Symptoms go away but a year later they return again. Cardiologist increase A,B,C,D to 30mg and symptoms disappear. What is the limit to which you should increase medication? is there one? In reality you can remove any discomfort with medication, such as morphine every few hours but how do you draw the line and decide when medication is no longer the answer. I definitely agree medication is the best first stage but I am wondering where the line is drawn.

[kenkeith]

"The COURAGE study didn't address the quality of life issue."

>>>Generally, how does quality of life change with any of the available therapy?  Available therapy justs treats the symptoms, and COURAGE study addresses longivity with the available treatment...it appears to be the same in terms of years of remaining life.

If symptoms can only be relieved with intervention, then that would be the preferred treatment...that is your experience.  Sometimes stent implants do not relieve chest pain, a clot from the procedure can cause a heart attack, and there can be restenosis (another occlusion), etc. I am merely expressing the thought not go for intervention if medication relieves symptoms.  Later, there may not be any choice and a stent implant or bypass can be done at that time...that option will remain open without any additional risk, there are exceptions!

[Flycaster305]

You have been left with lots of stressful decisions.  

The COURAGE study didn't address the quality of life issue.  I tried to resolve my blockages with drugs, exercise, and diet, but continued to have angina and finally heart attacks, rejecting stents or bypass.  For whatever reason, I don't grow good collateral arteries that some people develop to feed oxygen to the heart in areas where blockages are present.  Stents greatly improved my heart function, combined with drugs, exercise, and diet.  I have four drug-elluting stents and four bare-metal stents.  The drug-elluting stents are a bit larger and didn't fit my tortuous, small vessels.  I've had no problem with restinosis of the bare-metal stents because of plavix and aspirin therapy.

All of us with heart trouble on this board come with different experiences, so we have different messages.  I'd strongly recommend you get a second opinion.  Leaving a patient in charge of such a decision demands it.  Keep us informed.

[ed34]

Different people will give you different opinions based on experience. So, here's my shot.
I would opt for the stents any day. Why? because I was told that a triple bypass would return me to normal life and would last the rest of my natural life. WRONG. All that pain I went through for 3 months benefits.
I've had a stent in my LCx now for three years and it's still fully patent with no restenosis at all. If you go for stents, for goodness sake please ask them to ensure they use drug eluting ones and not bare metal.
That's my personal opinion, so I will now pass the microphone over :)

[kenkeith]

Google COURAGE study.  That is a study that was done to evaluate the different options available.  Your doctor isn't much help to suggest you pick your poisen.  Obviously, the choice would be the least interventional procedure. I have a totally blocked LAD with collateral vessels feed into the deficit area, and a 72% blocked ICx..I do well on medication for the past 6 years.