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STUDY FINDS MUCH HEART BYPASS SURGERY CAN BE PUT OFF OR AVOIDED

By JANE E. BRODY Published: October 27, 1983 FACEBOOK TWITTER GOOGLE+ EMAIL SHARE PRINT REPRINTS BETHESDA, Md., Oct. 26— A

substantial number of patients who undergo coronary bypass surgery could safely postpone the operation and perhaps avoid it entirely, according to the findings of a 10-year national study released here today. The researchers estimated that 25,000 of the 170,000 bypass operations each year do not significantly improve these patients' chances of survival over the next six years. The patients are those with mild to moderate chest pain and those without pain but who have already suffered a heart attack. There was no suggestion that surgeons were at fault in operating in the cases where survival rates were not improved; rather, that new data now give them the knowledge with which a decision can safely be made to put off surgery at least for a time. Even though these patients may have blockages in one or more coronary arteries, postponing surgery that bypasses the obstructions does not diminish their chances of survival, the study showed. At the end of six years, 92 percent of those who had surgery and 90 percent of those treated only with medications were still alive, a difference that is considered statistically meaningless. According to Dr. Thomas Killip, cardiologist at Henry Ford Hospital in Detroit who was chairman of the study's steering committee,

''Patients who fall into the symptom categories in this study pay no mortality penalty for postponing surgery until and unless symptoms worsen.'' Surgery was found to improve some measures of the quality of life. For example, those who underwent surgery had less pain, needed fewer medications and could exercise more. However, there was no difference between the surgery and medication groups in the proportion who returned to work and in the ability to participate in recreational activities. Previous studies had shown that coronary bypass surgery, which now costs individual patients an average of from $15,000 to $25,000, is lifesaving for patients who have a major blockage in the main left coronary artery.

Earlier research has also shown the value of the operation to patients with the crippling chest pains of severe angina. The present study did not challenge the advisability of surgery for these patients. However, patients with milder symptoms of coronary artery disease have been a dilemma to physicians in the 15 years since bypass surgery was introduced.

Knowing these patients had blockages in one or more arteries feeding the heart prompted many physicians to recommend surgery in hopes of staving off a fatal heart attack. ''We now know that it is safe to wait to operate if and when the patient's symptoms get significantly worse,'' said Dr. Eugene Passamani, associate director for cardiology at the National Heart, Lung and Blood Institute, which financed the 15-center study. ''The next stage of mild angina is not a heart attack or sudden death but rather a worsening of the angina.'' In fact, the doctor said, it may be safer to wait since surgery does not cure the underlying disease, which usually progresses even after a bypass operation. By 10 years after surgery, the grafted vessels have closed in 40 percent of patients and in the remaining 60 percent, half develop further significant narrowing of coronary arteries. Dr. Passamani pointed out that bypass surgery is safest and most effective the first time it is done, ''so it may pay to wait until it is really needed.'' The new study showed that each year, on average, symptoms worsen enough to warrant surgery in about 5 percent of patients with mild to moderate angina. Postponing surgery until that happens could save approximately $500 million a year in medical costs, the researchers estimated.

The study was conducted among 780 patients who were randomly assigned to be treated either with surgery or medication. All patients were advised to change their cardiovascular risk factors, such as to stop smoking, eat less fat and cholesterol, get more exercise and lose weight. However, few patients in either group heeded this advice. Whereas 40 percent were cigarette smokers when the study began, more than 30 percent were still smoking five years later. Only a few percent became participants in a supervised exercise program and the incidence of overweight and high cholesterol actually increased in the study period. Six percent of those operated on were found to have suffered heart attacks as a result of that treatment.

The death rate from the bypass operation is 1.3 percent at top medical institutions, which is regarded as a good safety record for this kind of surgery.

The New York Times