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Lifesaver or Billion-Dollar Industry?
by author Julian Whitaker, MD

Coronary artery bypass surgery took centre stage in 2004 when former US President Bill Clinton underwent emergency bypass surgery. Complaining of mild chest pain and shortness of breath, Clinton had an angiogram, which revealed blockages in his coronary arteries, and was rushed into quadruple bypass surgery.

If you followed any of the news coverage of Clinton’s surgery, you’d think that surgery saved his life. The chief of cardiology at the hospital where Clinton had his surgery underscored the necessity for immediate intervention, and Clinton himself was quoted as saying that without the quadruple bypass, there was a 100-percent chance that he would have had a heart attack. Cardiologists interviewed on morning talk shows spouted off about the benefits of bypass, and newspaper articles detailed lifesaving breakthroughs in interventional cardiology.

The public bought it. Hospitals reported a jump in emergency-room visits by middle-aged men with chest pain, anxious to find out if they too needed bypass surgery. Imaging centres experienced a surge in appointments for heart scans and other screening tests for heart disease. Patients in record numbers consulted their physicians to see if bypass surgery or angioplasty, a less invasive means of opening blocked arteries, was their best course of action.

There’s just one problem. Even though more than half a million bypass surgeries are performed in North America every year (most of them in the United States), there is virtually no scientific evidence showing that, except for a small subset of patients, those having surgery live longer or have fewer heart attacks than those who don’t. Let’s look at the evidence.

Lifesaving Surgery?

The first coronary artery bypass surgery was performed in the early 1960s. Because it helped relieve chest pain, it was assumed–even though there were no scientific studies to support this assumption–that it also prevented heart attacks and improved longevity, and over the next decade its popularity spread like wildfire.

The first study of bypass surgery, the Veterans Administration Cooperative Study, wasn’t published until 1977, and its results ran 180 degrees counter to expectations. The study showed that, contrary to popular belief, bypass surgery did not save lives or prevent future heart attacks. In fact, it offered no significant benefits over treatment with medications.

You’d think that this would have ended the “bypass era.” However, so many cardiologists and medical centres had jumped on the bypass bandwagon that this study was simply ignored. Eugene Braunwald, MD, of Harvard Medical School warned in an editorial in the New England Journal of Medicine that “an industry is being built around this operation…This rapidly growing enterprise is developing a momentum and constituency of its own, and as time passes it will be progressively more difficult and costly to curtail it materially if the results of carefully designed studies of its efficacy prove this step to be necessary.”

Dr. Braunwald’s words were prophetic. In 1983, the results of the most comprehensive, “carefully designed” study of bypass surgery ever done, the Coronary Artery Surgery Study (CASS), dramatically underscored the results of the earlier study. After five years of follow-up, bypass surgery neither improved longevity nor reduced heart attacks compared to nonsurgical treatment–even in patients with blockages in three of their coronary arteries. The annual death rate of patients treated conservatively was so low (less than 2 out of 100 patients per year) that it was impossible for bypass surgery to improve on it.

The CASS researchers published follow-up data on study participants in 1990 and again in 1995, and again found that bypass surgery did not prevent heart attacks or prolong life, nor did it make a difference in terms of the presence of angina, use of medications, frequency of heart failure and hospitalization, and activity limitations.

Yet, as Dr. Braunwald predicted, none of these studies, which were far more damning of the procedure, stemmed the growing popularity of bypass surgery. Neither did the European Coronary Artery Surgery Study (the only other large clinical trial to date comparing bypass to conservative medical therapy), nor any of the handful of subsequent smaller studies reaching the same conclusions.

Julian Whitaker, MD, practices medicine at the Whitaker Wellness Institute in Newport Beach, California (whitakerwellness.com), and writes the monthly newsletter Health & Healing (drwhitaker.com).

Source: alive #268, February 2005