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How Old is Too Old for Bypass Surgery?

2/14/2004      

SATURDAY, Feb. 14 (HealthDayNews) -- Gripping pain rips across your chest each time you climb the stairs. X-ray images show you may be a candidate for heart bypass surgery.

But if you're 75 or older, do you dare take the risk?

Age is certainly a consideration for such strenuous surgery. Research shows older people are more likely to die during or after the operation than younger patients. And elderly patients who survive a bypass can expect longer recovery times.

On the other hand, a study published recently in the Journal of the American College of Cardiology says bypass surgery isn't just for the young. Older people can see improvements in their quality of life, too.

"Our study was really an attempt to provide some insights into what are the benefits of this treatment" for older patients, says Dr. John Spertus, a professor of medicine at the University of Missouri-Kansas City. Spertus also serves as director of cardiovascular outcomes research at the Mid America Heart Institute of Saint Luke's Hospital in Kansas City.

Coronary artery bypass surgery is a major operation for restoring blood flow and oxygen to the heart. Patients with at least one clogged artery may be candidates for the surgery, which involves removing a healthy vessel from another part of the body and using it to make a detour around the blockage.

Increasing blood flow to the heart can relieve chest pain and reduce the risk of heart attack.

The American College of Cardiology (ACC) and the American Heart Association (AHA) last updated national guidelines for bypass surgery in 1999. The joint ACC/AHA task force concluded that age alone should not be a factor in advising against bypass surgery if the long-term benefits are seen as outweighing the risk of surgery.

Still, the decision to pick up the knife and operate on a patient is highly individualized. While surgeons may refer to those national guidelines, their interpretations of those guidelines vary widely, researchers say.

The question of whether to perform bypass on, say, octogenarians is really unique to America, notes Dr. David B. Nash, chairman of the department of health policy at Jefferson Medical College in Philadelphia.

"No other country does bypass on 85 years olds," he says. "It's a resource allocation issue."

To see how well older people fare, Spertus and his colleagues asked 690 people undergoing coronary bypass surgery to assess their quality of life and physical functioning before surgery and one year later. One hundred fifty-six of them were over 75.

The research team also asked the first 224 volunteers to complete monthly questionnaires in the first six months after surgery.

Of the 16 surgery-related deaths that occurred, four involved older patients. The mortality rate for the elderly was 2.6 percent, slightly higher than the rate for younger people. Patients over 75 also were more likely to die in the year after surgery than those under 75.

Yet despite a slower recovery period, people over 75 fared just as well as the younger group, realizing similar relief from symptoms, improvement in physical function, and quality of life.

What remains unclear is how older people who have bypass fare compared with people of their age group who pursue alternatives to surgery, such as angioplasty, says Edward Hannan, chairman of the department of health policy, management and behavior at the University of Albany School of Public Health in Albany, N.Y.

Ideally, he says, more research is needed to compare outcomes at one year, five years, and 10 years after the procedures. Those studies should look at death rates, complications, need for revascularization, and long-term survival.

So based on what is known, who makes a good candidate for bypass surgery?

In general, people who are really bothered by the symptoms of angina are good candidates, Spertus says. "The most important question is, 'Am I going to feel better after the procedure than I do now?' "

Patients considering bypass also should make sure their physicians have ruled out surgical alternatives, like angioplasty with stenting, surgeons say.

In addition, bypass candidates who suffer from other health problems, such as lung disease and diabetes, need to be advised of the increased risk that surgery poses for them, says Dr. Thomas Nicosia, director of cardiology at St. Francis Hospital, a cardiac specialty hospital in Roslyn, N.Y.

Cardiologists also should carefully consider whether to attempt bypass on patients with neurologic impairment, who have suffered a stroke or are mildly senile. "The quality of life and trauma of surgery may not be fully grasped by the patient," Nicosia explains.

Nash advises patients to choose a hospital that does a reasonable volume of such surgeries a year. "For me, that would be 200 cases or more," he says.

Patients also should meet with the operating team before surgery and ask questions about post-surgery complications and mortality for their specific age group, he adds.

"That information should be readily available," Nash insists. "If it's not, rotate 360 degrees and exit the office."

More information

To learn more about heart bypass surgery, visit the National Library of Medicine and the American Heart Association.

SOURCES: John Spertus, M.D., professor of medicine, University of Missouri-Kansas City, and director of cardiovascular outcomes research, Mid America Heart Institute, Saint Luke's Hospital, Kansas City, Mo.; David B. Nash, M.D., M.B.A., chairman, department of health policy, Jefferson Medical College, Philadelphia; Edward Hannan, Ph.D., professor, and chairman, department of health policy, management and behavior,e University of Albany School of Public Health, Albany, N.Y.; Thomas Nicosia, M.D., director of cardiology, St. Francis Hospital, The Heart Center, Roslyn, N.Y.; Oct. 15, 2003, Journal of the American College of Cardiology

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