DEAR DR. ROACH: I am a 70-year-old, retired, white male with no major health history, who is not overweight, diabetic or a smoker. All my bloodwork and my blood pressure are within range for my age. I have had a very healthy diet for a long time, lead a sedentary lifestyle and have some family history of heart-related issues, primary being my mother’s heart-attack death at 64. However, she had numerous major health events throughout her life and was a heavy smoker with a poor diet, etc. I have had some recent mild symptoms: occasional shortness of breath and three incidents of chest tightness over 90 or so days. My physician ordered a treadmill test. My cardiologist had some concerns about the test result, and I had a follow-up catheterization three weeks ago. As a result, it’s been strongly recommended that I have bypass surgery.
I am cautiously active, doing light yardwork, washing the car, etc. Except for the catheterization, I have never had any medical events or procedures.
My concerns with the bypass are my current asymptomatic condition, associated risks, possible side effects, duration of effectiveness and the extensive recovery period. I have researched noninvasive alternatives and have become knowledgeable regarding EECP. I have scheduled a consultation. My cardiologist doesn’t support EECP, and my PCP is ambivalent. I would like your opinion regarding EECP in general as a viable alternative to invasive procedures. I was told that stents are not an option. I currently am not taking any heart medications. — Anon.
ANSWER: There are two reasons to treat coronary artery disease (blockages in the arteries of the heart): The first is to relieve symptoms, and the second is to prevent a bad outcome, such as heart attack and death.
There are several ways to relieve symptoms, including medications, catheter-based procedures and surgery. Medications like beta blockers, calcium blockers and nitroglycerine all can help with symptoms. (They can help prevent heart attack and death, too, along with aspirin and a statin.) Catheter-based treatments, especially angioplasty and stent (angioplasty uses a balloon on a wire to open the blockages, then a stent helps keep them open), also improve symptoms. Surgery does as well, but because it is so invasive, for the reasons you mention it is much less frequently used now.
Enhanced external counterpulsation (EECP) is a newer technique using, essentially, blood pressure cuffs around the legs and pelvis that squeeze when the heart is relaxed, to provide additional blood flow. It is recommended for people with symptoms that have not been amenable to other treatments. Since you aren’t on treatment, I don’t think it is worth considering yet. If you had symptoms despite medicines, stenting would be the most frequently recommended treatment. I don’t know what in your particular anatomy makes your cardiologist feel stents are not appropriate.
There are a few situations when surgery is recommended as the best treatment to prevent heart attack and death — for instance, people with significant disease in the left main coronary artery, or people with many blockages. I don’t have enough information to say whether this is the case with you, but if your cardiologist is recommending surgery, I would ask whether this is recommended to prevent your death, and I would take the answer very seriously indeed.
