Q. A 72 year old diabetic patient had heart attack with multiple blocks. Is bypass advisable?

Answered by
Dr. Sagar Ramesh Makode
and medically reviewed by Dr. Hema
Published on Oct 18, 2019 and last reviewed on: Oct 21, 2019

Hello doctor,

The patient is 72 years old male and moderately active.

Symptoms:

Initially, the patient reported moderate pain in chest and weakness. The patient was given medicine for gas. Since the symptoms continued for a couple more days, he also felt pressure and discomfort in the chest, he was referred to urgent care for cardiac evaluation.

Diagnoses:

1. NSTEMI heart attack.

2. Troponin-I was 9.14.

3. Angiogram revealed a TVD (Triple Vessel Coronary Disease).

4. LAD has 80% stenosis in the ostioproximal part with 90% distal disease.

5. LCx has 95% stenosis in its mid part (nondominant).

6. LMS has a mild disease in its distal part.

7. RCA Dominant with a moderate disease in its proximal part.

History:

The patient does not have any history of heart disease and not ever flagged with any heart-related issue in past routine checkups.

Risk factor:

DM (Hba1c 8.2 ). A few months ago, Hba1c shot up to 11 / 12. Medicine was adjusted to pull it back to a reasonable range.

HTN, the patient had a change in the job a couple of months ago, which added moderate stress. CKD (managed with borderline creatinine).

Recommendations:

CABG (Bypass surgery).

Is CABG the preferred option for this case over angioplasty and stenting? What are the pros and cons of these options?

We are told to perform the operation in two weeks. What is the risk of waiting longer?

Assuming going with CABG, we also need to decide where to perform the procedure, in the local cardiac facility, or more reputed internal hospital within 3 to 4 hours of flight. How are the factors to consider? Is CABG a fairly common procedure with similar regimens?

Dr. Sagar Ramesh Makode

Cardiology General Medicine Internal Medicine
#

Hello,

Welcome to icliniq.com.

Considering the blockages at multiple sites, which will require multiple stents to treat and his diabetic status says, the life of the stent is relatively shorter. CABG (coronary artery bypass grafting) is a preferred option.

CABG involves the major surgery where risk is higher, say around 4 % (varies from center to center), and recovery takes longer. Stenting has a lesser risk of around 1 % but with a shorter life of stents.

So CABG is the first choice, but stenting is an option if you are not willing for CABG. It is better to get it done early as there is a risk of a repeated heart attack. However, the risk of such attacks is minimum with medicines but not eliminated.

CABG is a fairly common procedure nowadays and considering his age, it is better to perform at a higher center. So both options are available, but CABG is preferable.

I hope this helps.

Thank you doctor,

Thanks for your prompt response. It is assuring that your recommendations are matching with the opinion of my local cardio surgeon. A have a follow up question. Is the risk rate (e.g., mortality rate) of a center usually available ? If not, what things should one check about the center to ensure they are of a reasonably high standard for CABG ?

Dr. Sagar Ramesh Makode

Cardiology General Medicine Internal Medicine
#

Hi,

Welcome back to icliniq.com.

No, mortality rates are not usually available for comparisons. It depends on overall reputation of hospital and how big is their setup. Few things to be checked are the cardiac surgeon who is performing the surgery, his experience, reputations, reviews online or from local public. Higher centres with bigger setup tend to have a skilled surgeon and better appliances compared to local smaller centres.

So, this is not a very straight forward decision and you need to collect some information from locals, but in general higher centres have better results.

Also, this is a quite common surgery now a days and even lower centres perform it well.

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