Thursday, June 12, 2008

Heart Surgery Can Damage The Brain, Probably Won't Prolong Life

I ran across this:

Is Heart Surgery Worth It?, Business Week, July, 2005

Excerpts... First, setting the stage:
"You start breathing hard after climbing stairs, and your chest hurts. You go to your doctor. Scans reveal that arteries feeding your heart are severely narrowed. Your doctor sends you to the hospital for coronary bypass surgery or angioplasty to restore the blood flow to your heart. Despite the trauma of surgery, you're glad the blockage was caught in time, saving you from a potentially fatal heart attack."
Now, the questions...
"There's just one problem with this happy tale of modern medicine: More and more doctors are questioning whether such heart procedures are actually extending patients' lives."

"The data from clinical trials are clear: Except in a minority of patients with severe disease, bypass operations don't prolong life or prevent future heart attacks. Nor does angioplasty, in which narrowed vessels are expanded and then, typically, propped open with metal tubes called stents."
So, why are we doing 400,000 bypass surgeries and one million angioplasties a year?
"The heart-surgery industry is worth an estimated $100 billion a year."
$100 billion. Just for heart surgeries. Just in 1 year. That's a lot of money.
But heart surgery relieves angina ... or does it. Enter the placebo effect:
"Recent studies even raise questions about whether surgery causes the symptom relief. In June, Harvard Medical School associate professor of medicine Dr. Roger J. Laham reported on follow-up results of a randomized trial looking at laser surgery to improve blood flow. Patients who got the surgery had significantly less pain and improved heart function. But so did patients who had a sham operation -- the equivalent of a placebo."

"After 30 months the placebo effect was still there. Scans and other tests showed physiological gains in blood flow among only those who thought they had been operated on. A similar large placebo effect might explain "most of the benefits that we've seen so far with balloon angioplasty and bypass surgery," Laham says."

I ran across the article above after reading about Bill Clinton, and why he's been acting odd:

'Bypass Brain': How Surgery May Affect Mental Acuity, Wall Street Journal, June 10, 2008

The following implies that the reason our former President has been perhaps a little less predictable is due to microscopic strokes:
"When a patient's blood is pumped through a heart-lung machine during bypass, tiny air bubbles, fat globules and other particles may enter the bloodstream. The pump can also damage platelets, which form clumps, and clamping the aorta loosens bits of plaque. That debris can travel to the brain and clog tiny capillaries, forming microscopic strokes."
How many people does this effect? Over half of patients in a cited NEJM study had significant cognitive decline upon discharge. Here's a more recent study that suggests more than that may suffer brain damage:
"Researchers at Johns Hopkins School of Medicine have been following 152 bypass patients, another 92 treated with medication or stents and a group of healthy controls. They reported in the Annals of Neurology last month that after six years, all the patients with coronary-artery disease had cognitive decline -- no matter how they were treated. The healthy patients didn't."
Hard to say whether surgery, or heart disease itself led to that decline, since everyone who had heart disease also had intervention.

Proponents of those $100 billion-a-year heart surgeries, most of which won't prolong life or prevent another heart attack, say "cognitive decline should be viewed as a minor and transient risk." (That quote is from Timothy Gardner, cardiothoracic surgeon and president-elect of the American Heart Association. The same American Heart Association that recommends someone improve their health by eating 0.5 ounces less of a fast-food sausage egg biscuit.)

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