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Which is better, bypass surgery or angioplasty?

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The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Medically reviewed by

Dr. K. Shobana

Published At April 4, 2021
Reviewed AtJuly 7, 2023

Patient's Query

Hi doctor,

This is for my dad, who is 64 years old. His blood pressure went up to 220 mm Hg, and then they took him to the cardiologist for an opinion, and they did all the tests and said he has three blocks in three of the main arteries and needs triple bypass surgery. I need your second opinion if this is the best solution? Is open heart surgery going to fix the high blood pressure issue? Is high blood pressure caused due to heart blockage? What are the cause and effect? If we have to do the surgery, what is the advantage and what is the risk? Can these blocks be fixed by angioplasty? How severe is this condition? My dad did not experience any symptoms like fatigue or chest pain. He was as normal as he can be? Are high blood pressure and blocks in arteries heart-related? Can we do stent using angioplasty instead of open-heart bypass surgery? Or is there any less invasive approach? Kindly let me know if you need any other details.

Hello,

Welcome to icliniq.com.

I have seen all your reports (attachment removed to protect the patient's identity). Heart surgery is not associated with blood pressure. High blood pressure is a risk factor for coronary artery disease, and controlling blood pressure with medicines and lifestyle modifications will slow the progression of coronary artery disease. High blood pressure is not caused by heart blockage. Heart blockage is also not caused by high blood pressure. Rather, high blood pressure is a risk factor for heart vessel blockage. Bypass surgery will provide blood to the heart, which is reduced by stenosed arteries. It has mortality benefit, which means it reduces the risk of death, reduces the risk of cardiac arrest, improves symptoms, and prevents the heart from weakening due to reduced blood supply. If done successfully by an experienced surgeon, the risk is minimal. Some risks which are common to all surgeries include pain, infection, bed rest, hospital admission. Other risks include chest infection due to ventilator, minimal chances if sterile measures are taken. But it will need a lot of stents to be placed in your coronary arteries with increased risk of blockage in stents, high cost, and no benefit in reducing the risk of death. Only symptoms may improve, but the risk of death is not decreased. A large number of stents will increase the risk of blockages which may cause heart attack and later weakening of heart muscles. All three vessels plus the left main artery are narrowed, which causes a high risk of heart attack, cardiac arrest at any time. One reason for no symptoms may be that blockages progressed slowly, and your father may have a sedentary lifestyle. Slow blockages cause new vessels to be developed automatically over time which provides blood to the heart via alternate roots. This is sometimes called "auto-bypass." But angiography does not mention new vessels. High blood pressure is a risk factor for coronary artery blockages. Blood Pressure needs to be controlled to reduce the risk. Angioplasty can be done, but it has a high future risk of stent thrombosis, as I mentioned. It should be attempted if the surgeon says that bypass is not possible and the patient is having chest pain despite maximum medicines. The other options are medicines, enhanced external counter pulsations (EECP), spinal cord stimulation, coronary sinus construction. But these are only beneficial in terms of chest pain symptoms and have no mortality benefit. Moreover, these techniques are used very less often in case when bypass and angioplasty, both are not possible, and despite maximum medicines, the patient has chest pain.

Patient's Query

Thank you doctor,

Does the ECG show signs of heart abnormality? I am trying to understand why we were recommended to do the angiogram in the first place. Does the ECG show abnormality only on the left artery and not on the right (since all of the angiograms seem to be focusing on the left side)? Is it possible to have so many regions of blockage on the left artery but not on the right? Is this image showing our understanding of the blockages and bypass routes correct? In general, does the mortality risk follow this order? Angioplasty with a stent, bypass, angioplasty without stent Given this risk, is it possible to do balloon angioplasty without a stent? In your opinion, considering males at 64 years, can you state a percentile (number) (with respect to population going through heart surgery) on the severity of these blockages? Also, what is the success or recovery rate from doing open heart surgery in this case?

Hello,

Welcome back to icliniq.com.

ECG (electrocardiogram) is not a sensitive test for subclinical atherosclerosis. ECG shows changes only in case of heart attack, chest pain. On rest, usually, ECG does not show changes. It will show changes if the demand for blood to the heart increases, as in exercise. Thats why normal ECG on the baseline is followed by stress ECG or stress echocardiography if the probability is intermediate. In case of high probability or the clinician's high suspicion of coronary artery disease, direct angiography is advised. ECG can show abnormality in both the left and right heart. Angiography shows blockage in left and right-sided arteries. Some patients have only a single artery disease, such as only the left anterior descending artery, some have a blockage in two arteries, and some have a blockage in three arteries. Angiography shows correct, but the bypass is not decided only on the report. It depends upon which vessel is involved, to how much extent, and which area of the artery is involved? What is heart function? What are other diseases the patient is suffering from, such as diabetes and kidney disease? And what is presentation mean whether the patient came with a heart attack or just angina pain? Angioplasty without a stent is an outdated procedure and is rarely performed nowadays. Balloon angioplasty is not done nowadays as it has more than a 50 percent chance of re-blockage in a short time. So, now in the era of modern 3rd and 4th generation stents, balloon angioplasty is rarely performed. If bypass conduits are available and targets are good as assessed by a cardiac surgeon, the success rate is more than 95%. There is a 30-40% risk of re-blockage of venous grafts over ten years period, but it is less than multi-vessel angioplasty with multiple stents. In the case of arterial grafts, patency over 20 yrs is more than 90%.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Muhammad Zohaib Siddiq
Dr. Muhammad Zohaib Siddiq

Cardiology

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