Stent Or Bypass: Which Is Better For Treating Heart Disease In Diabetics?

Sooner or later, most people who live with diabetes also wind up with coronary artery disease. The combination of years of high blood pressure, high triglyceride levels, high cholesterol, and inflammation team up with imperfect injury repair to create clogs in coronary arteries, and at some point, it's just not possible to keep on going without getting blood vessels open again.

When that happens, interventional cardiologists offer angioplasty, percutaneous coronary intervention (also known as stents), and coronary artery bypass grafts (also known just as bypass).

You don't want to get on the operating table, as I did, and learn that your doctor has gone for the low-cost option that will require more surgery later, when you are just awake enough to hear what is going on and not awake enough to raise your hand and object. Here's what every person with diabetes needs to know about surgical heart repair options, preferably before they are being put under anesthesia.

What Are the Options for Fixing Clogged Arteries in Diabetics?

If statins or chelation therapy or diet or orthomolecular supplementation programs have not worked for you, and you need vascular repair and you need it now, doctors have three general options:

• Angioplasty. This surgical procedure consists of placing a balloon into a blood vessel, inflating it, moving it around, and breaking up cholesterol deposits inside an artery to open the vessel up again. The surgeon uses a tiny camera on the end of a catheter to see the lesions and to monitor progress of the procedure.

• Stent. This consists of insert a wire mesh coil, which is artfully inflated once it is in place, into an artery to keep it open after cholesterol deposits have been broken up. This almost always follows angioplasty.

• Bypass. The surgeon takes a vein from a leg and then opens the chest to attach it to the coronary artery during a bypass procedure. Usually the heart has to be stopped and the patient placed on a bypass machine to take care of oxygenating and circulating blood during the procedure.

Recovery from angioplasty and stents can be very fast. Some patients go home the same day and feel great. Recovery from bypass is much slower. It is not unusual for it to take a year for patients to get back to feeling normal, like they did before the surgery. But doctors don't always tell their diabetic patients everything they need to know about their cardiovascular repair options.

What Doctors Often Don't Tell Diabetics About Heart Surgery

If you are having a heart attack, your doctor may not have a chance to tell you everything about your procedure before you have it, because they are too busy saving your life. And if you don't have good enough insurance to pay for an expensive procedure you really need, the doctor may simply "forget" to mention the possibility to you. But here are some basic facts every diabetic needs to know before you have surgery.

• Stents are permanent. They can't be removed. When you get a stent, usually the artery can't be repaired by bypass later. 

• Stents can fail. Usually the problem is scar tissue growing through the stent and blocking the artery all over again. It's extremely important to take your statins (not for lowering cholesterol, but for lowering inflammation), your anticoagulants, and your blood pressure medications for 6 months to a year exactly as prescribed. The artery can also "blow out" around a stent, a dramatic event that can cause sudden death. This isn't likely unless you undergo a series of stent operations (say, 3 in 3 days) in a short time period.

• Diabetics typically need drug-eluting stents. These stents are coated with a medication to prevent the formation of scar tissue. They cost more than bare-metal stents. If the hospital is giving you the operation at a discount, they may give you the bare metal stents that are more likely to fail later. If you are in any position to, advocate for the drug-eluting stent.

• It's a lot harder to recover from bypass than from stent placement. And you will almost certainly be discharged from the hospital before you can take care of yourself. Have someone in place to look after you while you recover from your surgery.

• Bypass is also enormously more expensive, about $250,000 versus $25,000 for an uncomplicated procedure.

Read More: Diabetes Is a World-Wide Problem and Out of Control

A landmark study published in the Journal of the American Medical Association found that people with diabetes do better after bypass than stents. And to its credit, the JAMA Journal is being honest about the details.

Stents and Bypass Result in Approximately Equal Quality of Life

The Journal of the American Medical Association reported the results of an ongoing clinical study called the FREEDOM trial, in which 1,880 diabetes sufferers in 18 countries who had multiple blocked vessels underwent either coronary bypass graft surgery (947 diabetics) or multiple stent placement (933 diabetics). Doctors then followed the results of the surgery, and the patients' progress, for 2 years. Here is what they found.

• Diabetes patients who have bypass surgery are less likely to have a heart attack and less likely to die after the procedure than diabetics who get stents, but they are more likely to have strokes. Overall, the risk of further serious vascular disease and death is lower when diabetics get the bypass.

• Diabetics who have bypass surgery have less angina (chest pain) than diabetics who get stents, at least during the first two years after their surgery.

• Diabetics who have bypass surgery report better quality of life, less angina, and greater physical mobility than diabetics who get stents, although not by much. The FREEDOM researchers asked diabetics to use a 0 to 100 rating scale, and the differences between bypass patients and stent patients was just 1 to 4 pounds out of 100 in each group of questions.

If you have great insurance, if you have help at home, and if you don't have to work for a year or more, then there may be advantages to bypass surgery for you. Let your doctor explain them. But if you have to have treatment right away, and you are going to have to back to work right away, or you don't have help at home, ask about stents. Their long-term benefits seem to be slight. Ten years ago about 8 percent of bypass patients and about 13 percent of stent patients died within 5 years, but the latest data show that after two years, either treatment is likely to result in about the same chance of survival, and the stent procedure is far less traumatic.

If you keep up with the medical news, you would have seen headlines saying exactly the opposite to this as well, but the difference is that this particular study looked at results in the use of techniques available in the last few years. The other study looked at results of treating diabetics 10 years ago. Anticoagulant therapy has advanced a great deal over the past 10 to 15 years. Ask you doctor about your particular circumstances, making sure that you are informed about the risks and benefits of every option. And follow every recommendation for your recovery to the letter.