Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and I'd like to welcome you to my podcast station and to the Healthy Heart Network. I'd also like to welcome Dr. Alistair Begg, who is a close friend and a colleague with an interest in cardiac rehabilitation, who's based in Adelaide. He's a full-time practicing cardiologist and today we are going to be talking about stents versus bypass. Welcome, Alistair. Thanks, Warrick, and thanks very much for having me on your show once again. Great to be here. Oh, it's great to have you, Alistair. Thank you for making the time. Look, I'd like to get the ball rolling on this because a pretty common question that patients often have is why am I getting a stent and not a bypass or why am I getting a bypass and not a stent? What's going on? Which is right for me? I'm going to open up to that soon, but before I do, I guess we have to recognise that patients will present for evaluation, will present to their cardiologist in two main ways. One of them is in the back of an ambulance with chest pain, with a heart attack, and the other is a more controlled situation where a patient maybe is... recognized a decrease in exercise capacity over a period of time and then presents for evaluation. I'll get you to just touch on that very acute setting, that heart attack setting first of all. Tell me a bit about how things roll in that situation. Sure. Look, if someone has a chest pain that's severe and particularly if it's sort of starting to... and shortness of breath, pain radiating down the arms, then it's pretty obvious that they're having a heart attack and they should call an ambulance. Because really, as soon as the patient recognises that, the quicker they get to an emergency centre, the quicker that they can get that diagnosis and treatment, the more likely they are to survive, basically. Because once the artery starts blocking off, then it's like... a clock ticking, and the longer it goes, the more heart muscle actually dies. So it's very important that those symptoms are recognised early and that they are treated appropriately. And fortunately, we're seeing less people have these symptoms because more and more people are falling into that second group and getting checked out at an earlier stage, which is obviously a much better scenario where we can manage the situation and try and pick up a problem before it develops. And with appropriate recognition of risk factors and testing, many of those sort of situations can be avoided in the future. I think it would be fair to summarise that if you've got a blocked artery causing a heart attack, then generally the preferred management is to unblock that culprit artery as soon as possible. And we tend to do that in the... in the theatre, in the special catheterisation laboratory, using a stent, which is a wire mesh, a scaffold to open up that artery at the very time? Sure. Well, look, that's the preferred option. Certainly in Australia, about two-thirds of people live close enough to a centre with expertise in stents. One-third of the people still live in the country. And due to the time constraints of getting to a centre where someone can open up your archery with a balloon instead, we still use a lot of the clot-busting drugs in the country, and about a third of people would be in that group. But whatever the method, we know that getting the archery open saves lives. And time is muscle when it comes to opening an archery in a heart attack situation. That acute setting, all hands to the deck and we're trying to do as much as we can, as quick as we can to open up that culprit artery, whether it's by balloon and stent or the medications we use to unblock the artery, the thrombolysis. But let's talk more about if someone presents with symptoms for evaluation. Say a patient comes to you, a 62-year-old man, who has reported to his GP that he's getting some chest tightness and a little bit of shortness of breath when he climbs the stairs at work. If that patient comes to you, Alistair, what are your thoughts and how do you start to investigate him? Well, just by the nature of your introduction there, Warrick, I would say that that 62-year-old male who gets exertional chest pain or tightness, just by the fact that he's a 62-year-old male, it's highly likely that that symptom is actually due to his heart because that's one of the cardinal symptoms of heart disease is exertional chest pain or tightness. And certainly when we evaluate such patients, we take a pretty detailed history to make sure that it really sounds like a cardiac problem and not something else. And most of the information that we get is really through the history taking. We also examine the patient, look for changes in blood pressure and any sort of abnormalities on examination that would give an indication of an underlying cardiac problem. And then the patient will usually get an electrical tracing of the heart called electrocardiogram, which is the sort of sticky dots on your chest and it's connected to wires and goes through a computer and produces a graph. And from that, we can often work out whether there's been any blockages or developing problems. But then we usually do some sort of effort testing, and in that situation, something like an exercise test or an exercise stress ECG with or without some sort of imaging would more than likely show some problem indicating either a blocked or narrowed artery that's applying blood to the heart. And once we ascertain that, we would most likely do some sort of direct imaging of the arteries. dye or an ink, usually directly through the wrist or the groin through a little plastic tube called a catheter and take an actual picture of the outline of the arteries and identify whether there was a need for some intervention and more likely these days with a little artery opening medicine, with an opening device called a balloon and stent and that would be followed up with some medicine to keep the artery open. So I'm going to jump in there, Alistair, and offer some language, some definition of jargon that we use in the field for our podcast audience. And the two bits of jargon I want to share with them is this idea of a functional test, which is the word that we tend to use for the sort of stress test that you talked about. And when we're doing functional tests, we're very much asking, can we reproduce the symptom and demonstrate problems with the heart? Together with what's the functional capacity of that patient? How well are they performing? So we're looking at their function and then the injection of contrast into the arteries or injection of dye into the arteries to outline them. that gives us a picture or a roadmap which we call the anatomical information. So it's really the matching up of functional information and anatomical information that then guides appropriate treatment strategies, which may be medicines, stents, balloons and stents, or bypass grafting. Do you want to just talk briefly about those three? treatment options, medicines, balloons and stents, and they really go together. So we could just call it stents. It's very uncommon to use balloons without stents these days, although it is occasionally done. It's very uncommon. And bypass grafting. Do you want to talk about those three different sort of approaches to care and in what patients each would be most suitable? Sure, sure. Option of all those three, there will be a medication component. So that's the first thing. And that's usually some sort of blood thinning medication and some sort of medication to get the cholesterol down because that will obviously try and treat or prevent progression or prevent new problems developing of the plaques in the arteries. And the use of ballooning and stenting and bypass really depends. It depends on how many blockages there are, where they are, and how important they are in terms of prognostic and functional significance. So if it's in the main artery with lots of blockages and the patient, particularly if they have diabetes or loss of function of the heart muscle, they're more likely to need something more like bypass. Whereas if it's in... perhaps one artery or two, and the patient's not diabetic and there's no loss of function of the heart muscle and it's technically possible to treat with stents, then usually the stenting would be the preferred option. There's lots of factors, both technical and patient factors, that determine really where the stenting is the preferred option for bypass. Although, as I'm sure your listeners will be aware, most people these days prefer... the less invasive approach and where possible stents are used, but where either the blockages and narrowings are too extensive or where perhaps the prognosis is better with surgery, that's when the cardiologist will recommend an operation. I think to summarise that, the stents are probably most likely to be used in very discreet lesions. ones that could be covered by a stent that's, you know, a centimetre and a half long, for example. And coronary artery bypass grafting tends to be used in more diffuse or widespread disease and more often in people who are perhaps diabetic or with impaired function of their heart. Would that be a fair summary of the state of play, Alistair? Yeah, I think that's right at work. I mean, there's lots of... large trials or multi-centre randomised trials, we call them a medicine, and these trials more and more support the use of stents and certainly there are some subsets of patients such as, as you mentioned, patients with diabetes, perhaps patients with impaired function of the heart and certain anatomic areas that can't be accessed with stents that determine whether. You'll recommend bypass surgery or stents? I did see a trial come out only this year, Alistair, called the EXCEL trial, EXCEL trial, and this looked specifically at narrowing of the left main coronary artery, which is the biggest blood vessel that comes off the aorta to supply... the left anterior descending artery and the circumflex artery. So this single artery branches into two of the three main arteries of the heart. And historically, we've always thought of left main disease as needing surgery. Well, the Excel trial looked at that over a five-year period with several thousand patients and randomized them to either stenting or bypass grafting. Well, the outcome was that in the early stages, it seemed that the stenting group did better, but in five-year follow-up, it looked like the bypass group were doing better so that by the end of the five years of observation within the study, it seemed like both strategies worked pretty well equally. I think they're still continuing that observation to see if there's any... divergence or change at 10 years. But at this stage, it would seem in that situation that a decision made by the cardiologist and the surgeon as to the most appropriate way to deal with the anatomy for that individual patient is quite a reasonable approach. That's very interesting, Warrick. So I think there's been more and more studies coming out. As stent technology improves as well, the studies will be more and more refined. But certainly there's room in certain patients for stenting of that left main, and the indications are certainly getting broader as the technology improves. So we've covered plenty of stuff today. We've talked about... People presenting with a heart attack, needing their artery opened. We've talked about people presenting with symptoms and getting an evaluation, a functional test, and then getting their anatomy established by an invasive coronary angiogram to really delineate exactly what's going on in the arteries. And then we've talked about how we select either stenting or bypass grafting. depending on the suitability of the anatomy and some other aspects or characteristics of the patient. I think we've covered plenty of stuff today, Alistair. I really do appreciate your input and your sharing on that topic. I'm going to thank you so much for joining me and the Healthy Heart Network for this podcast. Thank you. Thank you, Warrick. As always, it's a pleasure to discuss things with you. Time always seems to fly when we discuss these things, so it must be enjoyable discussing it with you. We've gone for about 15 minutes already, Alistair, so I'm going to say goodbye. I'm going to say goodbye to those listening. I really hope you've learnt something from today's podcast. If you have any queries or questions, then shoot us a note on members at drWarrickbishop.online. Any suggestions for future podcasts, let us know on the same email address. Of course, until next time, I wish you the very best and please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
