More Than Coronary Artery Disease
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More Than Coronary Artery Disease
[There is] an unreasonable gap between the medical enthusiasm devoted to acute interventions and the meager efforts currently devoted to secondary prevention.
Rene C. Favaloro, MD
Pioneer of Coronary Artery Bypass Grafting
Interventional cardiology is symptomatic treatment. The late Dr. Lewis Thomas referred to this approach as "half-way technology," meaning that basic mechanisms of disease were not identified or treated. The bypass operation has significant mortality and morbidity, including further heart damage, stroke, and brain dysfunction. The benefits are at best temporary, since most grafts eventually close, and the patient faces further intervention or a life of progressive dis ability and death from the disease. Angioplasty has a 40% failure rate after 6 months,' as well as significant mortality and morbidity and, frequently, further heart damage.2 Variations to prevent restenosis include stenting with a wire cage, radiation to the balloon- fractured artery to compromise the inflammatory response, or use of a $1,400-per-dose drug to decrease the likelihood of thrombosis.
The futility of intervention as a strategy to avoid future acute coronary events or mortality is well recognized. The lesions targeted for intervention--those with >70% stenoses--infrequently account for sub sequent coronary events; this was documented re cently by serial angiography before and after coronary events.3 Furthermore, elective angioplasty does not decrease the risk of myocardial infarction or death. Bypass surgery does not decrease the risk of myocar dial infarction, and it benefits survival only in high- risk subsets.4
So, it seems we have an enormous paradox. The disease that is the leading killer of men and women in Western civilization is largely untreated. The juggernaut of therapy that has evolved for treating its symp toms consumes the lion's share of the available health- care dollars.5 The benefits achieved through great financial cost, morbidity, and mortality are at best temporary and erode over time, with most patients eventually succumbing to their disease. In cancer management, we refer to that approach as palliation. I refer to the present treatment of coronary artery dis ease as "palliative cardiology."
Why does the juggernaut persist? Because physi cians generally lack understanding of the techniques of lipid reduction through diet and medication. The belief also still prevails that the "quick fix" surgical repair of the major stenotic lesions will make things right. Finally, performing interventions has the poten tial for enormous financial reward. But the question remains: Aren't there other options?
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