By, Robert A. Wascher, MD, FACS
The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author. Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.
CABG SURGERY vs. PCI IN DIABETICS WITH CORONARY ARTERY DISEASE
Two weeks ago, I reported on a prospective randomized clinical trial that compared coronary artery bypass surgery (CABG) with coronary artery angioplasty and stent placement (percutaneous coronary intervention, or PCI). I noted that, based upon the early results of this clinical study, the jury may still be out regarding which of these two treatment approaches to coronary artery narrowing (stenosis) offers the best risk-to-benefit equation for most patients. Now, a new report, just published in The Lancet, has analyzed the results of 10 different prospective randomized clinical research trials comparing CABG with PCI in the treatment of coronary artery disease affecting multiple coronary arteries.
Altogether, the 10 clinical trials evaluated in this report included 7,812 patient volunteers. After an average of 6 years of clinical follow-up, 575 of the 3,889 (15 percent) patients who underwent CABG died, while 628 of the 3,923 (16 percent) patients who underwent PCI died. Therefore, overall, there was no difference in survival between the two treatment groups within 6 years of coronary artery intervention. However, when the researchers analyzed certain groups of patients undergoing coronary artery interventions, they discovered that diabetic patients appeared to do much better following CABG, rather than PCI. Among the patients with diabetes, survival at 6 years after treatment was 30 percent greater among those diabetic patients who underwent CABG when compared to the diabetic patients who underwent PCI. Similarly, patients over the age of 65 also appeared to do better with CABG. Among patients over the age of 65, survival at 6 years was 18 percent better in the CABG group when compared to the PCI group. For all other patients, however, there was no statistically significant difference in survival at 6 years between those patients who underwent PCI and those who underwent the far more invasive CABG surgery.
Approximately 1.5 million coronary artery interventions (CABG and PCI) are performed in the United States each year, and an estimated 25 percent of these patients have diabetes. So, a significant number of patients undergoing CABG and PCI also have diabetes. The results of this analysis are in keeping with the findings of previous studies showing that the coronary arteries of diabetic patients are more likely than those of non-diabetic patients to narrow again following PCI using balloon angioplasty, with or without the insertion of bare metal stents. However, recent advances in the development of drug-eluting stents and newer anti-clotting drugs have shown considerable promise in diabetic patients undergoing PCI with stent placement (among the 10 clinical studies included in this analysis, all patients receiving PCI underwent balloon angioplasty with or without bare metal stent placement, and no drug-eluting stents were utilized). Fortunately, there are several ongoing prospective randomized clinical research trials that will, hopefully, shed more light on the coronary artery restenosis rate in diabetic patients using the newer drug-eluting stents and glycoprotein IIb/IIIa inhibiting drugs. Unfortunately, we will have to await the publication of the findings of these ongoing clinical trials before PCI can truly be declared equal to CABG in diabetic patients. Therefore, at the present time, patients with diabetes, and especially diabetic patients with more advanced multi-vessel coronary artery disease (as well as diabetic patients with abnormal function of the primary pumping chamber of the heart, the left ventricle) are more likely to be advised to undergo CABG instead of PCI; although an increasing number of favorable-risk diabetic patients with complicated coronary artery disease are now being offered PCI with the newer drug-eluting stents and anti-clotting drugs.
As I concluded 2 weeks ago, the ongoing improvements in minimally-invasive PCI have definitely narrowed the gap in clinical outcomes between PCI and CABG over the past 10 to 15 years, and it is no longer clear that CABG (which is much more invasive than PCI, and more likely to cause stroke than PCI) offers any significant survival benefit over PCI, although CABG does appear to still provide a longer duration of improvement in blood flow to the heart than PCI (however, PCI can often be repeated, when necessary), and CABG may still be more appropriate for patients with more advanced cases of multi-vessel coronary artery disease.
Stay tuned, as I will continue to track the results of this very important area of clinical research, and I will keep readers updated as the ongoing “CABG vs. PCI” clinical research trials begin to report their results.
SWEETENED BEVERAGES AND CORONARY ARTERY DISEASE
We all know that we are in the midst of an epidemic of obesity in this country. Not only are adults heavier than ever before, but the incidence of overweight and obesity among our children has skyrocketed, and with this rising incidence of childhood and adolescent obesity, the incidence of other obesity-related diseases has also increased.
Multiple prior studies have linked the regular consumption of sweetened sodas and juices with excessive weight gain in both children and adults, and with a rising incidence of diabetes among both the young and old. Now, a new Harvard University clinical study of female nurses, just published in the American Journal of Clinical Nutrition, suggests that the regular consumption of sugary beverages may also significantly increase the risk of coronary artery disease as well.
In this prospective clinical study, nearly 90,000 women (ages 34 to 59) participating in the enormous Nurses’ Health Study were followed from 1980 through 2004. None of these women had any clinical signs or history of heart disease, stroke, or diabetes when they entered into this clinical research study. All of these women completed repeated and detailed dietary surveys during the 24-year follow-up period in this study.
Among these 88,520 female nurses, 3,105 developed coronary artery disease during the 24-year follow-up period. When the researchers analyzed intake levels of sugary drinks, they discovered that the increasing consumption of sweetened beverages was associated with an increased risk of coronary artery disease. When compared to women who consumed less than one sugary drink per month, consuming one sugary drink per day increased the relative risk of coronary artery disease by 23 percent, while the consumption of 2 or more sugary drinks per day increased the relative risk of developing coronary artery disease by 35 percent. When the researchers then accounted for differences in body weight, overall dietary caloric intake, and the presence or absence of diabetes among these women volunteers, the risk of coronary artery disease associated with the consumption of sweetened beverages was diminished somewhat, but still remained significant. At the same time, artificially sweetened beverages were not associated, at all, with coronary artery disease risk.
In summary, this enormous and ongoing clinical research trial, with nearly 90,000 women participating, found that, over a 24-year observation period, increasing levels of sugary drink consumption were associated with increasing levels of risk for coronary artery disease. At the same time, beverages that were sweetened with non-caloric artificial sweeteners appeared to carry no associated risk of coronary artery disease. So, next time you reach for a bottle of sugar- or fructose-sweetened juice or soda pop, give it another thought before you pop the top!
Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity
Dr. Wascher is an oncologic surgeon, a professor of surgery, a widely published author, and a Surgical Oncologist at the Kaiser Permanente healthcare system in Orange County, California
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Robert A. Wascher, MD, FACS
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Dr. Wascher’s Archives:
3-15-2009: Depression, Stress, Anger & Heart Disease
3-8-2009: Coronary Artery Disease: CABG vs. Stents?; Swimming Lessons & Drowning Risk in Children
3-1-2009: Aspirin & Colorectal Cancer Prevention; Fish Oil & Respiratory Infections in Children
2-22-2009: Health Differences Between Americans & Europeans; Lycopene & Prostate Cancer
2-15-2009: Statin Drugs & Death Rates; Physical Activity, Breast Cancer & Sex Hormones
2-8-2009: Hormone Replacement Therapy (HRT) & Breast Cancer; Stool DNA Testing & Cancer of the Colon & Rectum
2-1-2009: Obesity and the Complications of Diverticulosis (Diverticulitis & Bleeding); Obesity, Weight Loss & Urinary Incontinence
1-25-2009: Prostate Cancer, Fatigue & Exercise; Does your Surgeon “Warm-up” Before Surgery?
1-18-2009: Cancer and Vitamins; Teenagers, MySpace and Risky Behaviors
Exercise Reverses Some Effects of Fatty Meals; Vitamin C and Blood Pressure
1-4-2009: Secondhand Smoke & Heart Attack Risk; Poor Physical Fitness During Childhood & Heart Disease Risk During Adulthood
12-28-2008: Stress & Your Risk of Heart Attack; Vitamin D & the Prevention of Colon & Rectal Polyps
12-21-2008: Breast Cancer Incidence & Hormone Replacement Therapy; Circumcision & the Risk of HPV & HIV Infection
12-14-2008: Vitamin E, Vitamin C and Selenium Do Not Prevent Cancer; Postscript: A Possible Cure for Down’s Syndrome
12-7-2008: Generic vs. Brand-Name Drugs, Stress & Breast Cancer Survival
11-30-2008: A Possible Cure for Down’s Syndrome?; Smoking & Cognitive Decline; Calcium & Vitamin D & Breast Cancer Risk
11-23-2008: Breast Cancer & Fish Oil; Lymphedema after Breast Cancer Treatment; Vasectomy & Prostate Cancer Risk
11-16-2008: Vitamin E & Vitamin C: No Impact on Cardiovascular Disease Risk; Does Lack of Sleep Increase Stroke & Heart Attack Risk in Hypertensive Patients?
11-9-2008: Statins Cut Heart Attack Risk Even with Normal Cholesterol Levels; Statins & PSA Level
11-2-2008: Radiation Treatment of Prostate Cancer & Second Cancers; Sexual Content on TV & Teen Pregnancy Risk
10-26-2008: Smoking & Quality of Life
10-19-2008: Agent Orange & Prostate Cancer
10-12-2008: Pomegranate Juice & Prostate Cancer
10-5-2008: Central Obesity & Dementia; Diet, Vitamin D, Calcium, & Colon Cancer
9-28-2008: Publication & Citation Bias in Favor of Industry-Funded Research?
9-21-2008: Does Tylenol® (Acetaminophen) Cause Asthma?
9-14-208: Arthroscopic Knee Surgery- No Better than Placebo?; A Healthy Lifestyle Prevents Stroke
8-23-2008: Alcohol Abuse Before & After Military Deployment; Running & Age; Running & Your Testicles
8-12-2008: Green Tea & Diabetes; Breastfeeding & Adult Cholesterol Levels; Fish Oil & Senile Macular Degeneration
8-3-2008: Exercise & Weight Loss; Green Tea, Folic Acid & Breast Cancer Risk; Foreign Language Interpreters & ICU Patients
7-26-2008: Viagra & Sexual Function in Women; Patient-Reported Adverse Hospital Events; Curcumin & Pancreatic Cancer
7-13-2008: Erectile Dysfunction & Frequency of Sex; Muscle Strength & Mortality in Men; Cryoablation for Prostate Cancer
7-6-2008: Sleep, Melatonin & Breast Cancer Risk; Mediterranean Diet & Cancer Risk; New Treatment for Varicose Veins
6-29-2008: Bone Marrow Stem Cells & Liver Failure; Vitamin D & Colorectal Cancer Survival; Green Tea & Colorectal Cancer
6-22-2008: Obesity, Lifestyle & Heart Disease; Effects of Lifestyle & Nutrition on Prostate Cancer; Ginkgo Biloba, Ulcerative Colitis & Colorectal Cancer
6-15-2008: Preventable Deaths after Coronary Artery Bypass Graft (CABG) Surgery; Green Tea & Colorectal Cancer; Attention-Deficit/Hyperactivity Disorder (ADHD) & St. John’s Wort
6-8-2008: Vitamin D & Prostate Cancer Risk; Radiofrequency Ablation (RFA) of Kidney (Renal) Cancer; Antisense Telomerase & Cancer
6-2-2008: Acute Coronary Syndrome- Do You Know the Symptoms?; Green Tea & Lung Cancer; Episiotomy & Subsequent Deliveries- An Unkind Cut
5-25-2008: Early Childhood Screening Predicts Later Behavioral Problems; Psychiatric Disorders Among Parents of Autistic Children; Social & Psychiatric Profiles of Young Adults Born Prematurely
5-18-2008: Can Statins Reverse Coronary Artery Disease?; Does Breast Ultrasound Improve Breast Cancer Detection?; Preventive Care Services at Veterans Administration (VA) Medical Centers
5-11-2008: Smoking Cessation & Risk of Death; Childhood Traumas & Adult Suicide Risk; “White Coat Hypertension” & Risk of Cardiovascular Disease
5-4-2008: Super-Size Me: Fast Food’s Effects on Your Liver; Exercise, Weight & Coronary Artery Disease; Contamination of Surgical Instruments in the Operating Room
4-27-2008: Stents vs. Bypass Surgery for Coronary Artery Disease; The “DASH” Hypertension Diet & Cardiovascular Disease Prevention; Testosterone Therapy for Women with Decreased Sexual Desire & Function
4-20-2008: BRCA Breast Cancer Mutations & MRI Scans; Bladder Cancer Prevention with Broccoli?; Diabetes: Risk of Death Due to Heart Attack & Stroke
4-13-2008: Breast Cancer Recurrence & Hormone Replacement Therapy (HRT); Carotid Artery Disease: Surgery vs. Stents?; Statin Drugs & Cancer Prevention
4-6-2008: Human Papilloma Virus (HPV), Pap Smear Results & Cervical Cancer; Human Papilloma Virus (HPV) Infection & Oral Cancer; Hormone Replacement Therapy (HRT) & the Risk of Gastroesophageal Reflux Disorder (GERD)
3-30-2008: Abdominal Obesity & the Risk of Death in Women; Folic Acid Pretreatment & Heart Attacks; Pancreatic Cancer Regression after Injections of Bacteria
3-23-2008: Age of Transfused Blood & Risk of Complications after Surgery; Obesity, Blood Pressure & Heart Size in Children
3-16-2008: Benefits of a Full Drug Coverage Plan for Medicare Patients?; Parent-Teen Conversations about Sex; Soy (Genistein) & Prostate Cancer
3-9-2008: Flat Colorectal Adenomas & Cancer; Health Risks after Stopping Hormone Replacement Therapy (HRT); Television, Children & Obesity
3-2-2008: Medication & Risk of Death After Heart Attack; Hormone Replacement Therapy (HRT) & Mammogram Results; Selenium: Cancer, Heart Disease & Death
2-23-2008: Universal Healthcare Insurance Study; Glucosamine & Arthritis
2-17-2008: Exceptional Longevity in Men; Testosterone & Risk of Prostate Cancer; Smoking & Pre-malignant Colorectal Polyps
2-10-2008: Thrombus Aspiration from Coronary Arteries; Intensive Management of Diabetes & Death; Possible Cure for Down’s Syndrome?
2-3-2008: Vitamin D & Cardiovascular Health; Vitamin D & Breast Cancer; Green Tea & Colorectal Cancer
1-27-2008: Colorectal Cancer, Esophageal Cancer & Pancreatic Cancer: Update from the 2008 American Society of Clinical Oncology’s Gastrointestinal Cancers Symposium
1-20-2008: Testosterone Levels & Risk of Fractures in Elderly Men; Air Pollution & DNA Damage in Sperm; Statins & Trauma Survival in the Elderly
1-12-2008: Statins, Diabetes & Stroke and Obesity; GERD & Esophageal Cancer
1-7-2008: Testosterone Supplements in Elderly Men; Colorectal Cancer– Reasons for Poor Compliance with Screening Recommendations
12-31-2007: Minority Women, Hormone Replacement Therapy & Breast Cancer; Does Health Insurance Improve Health?
12-23-2007: Is Coffee Safe After a Heart Attack?; Impact of Divorce on the Environment; Hypertension & the Risk of Dementia; Emotional Vitality & the Risk of Heart Disease
12-16-2007: Honey vs. Dextromethorphan vs. No Treatment for Kids with Night-Time Cough, Acupuncture & Hot Flashes in Women with Breast Cancer, Physical Activity & the Risk of Death, Mediterranean Diet & Mortality
12-11-2007: Bias in Medical Research; Carbon Nanotubes & Radiofrequency: A New Weapon Against Cancer?; Childhood Obesity & Risk of Adult Heart Disease
12-2-2007: Obesity & Risk of Cancer; Testosterone Level & Risk of Death; Drug Company Funding of Research & Results; Smoking & the Risk of Colon & Rectal Cancer