MEDICINE CHOLESTEROL : Intestinal Bypass May Lower Risk of a Second Heart Attack

Heart-attack patients who undergo an intestinal operation to lower their cholesterol significantly reduce their risk of suffering another heart attack or dying of heart disease, according to a study in today’s New England Journal of Medicine.

The surgery, called a partial ileal bypass, reroutes the bowel to bypass about one-third of the small intestine. This reduces the amount of cholesterol that is absorbed into the bloodstream.

Dr. Henry Buchwald of the University of Minnesota, who directed the study, said this surgery should be considered as a possible treatment for people with high cholesterol who cannot bring it down enough by changing what they eat.

“It offers the strongest justification for marked lipid (cholesterol) intervention that has ever been offered,” Buchwald said. “It is a very powerful study and should, except for certain people who will never be satisfied, end the cholesterol controversy.”

But an important drawback is diarrhea, which afflicts virtually everyone to some degree after having the operation. Other possible side effects include a higher risk of gallstones, kidney stones and intestinal obstruction.

The study is called the Program on the Surgical Control of the Hyperlipidemias, or high cholesterol. It was conducted in Los Angeles, Minneapolis, Philadelphia and Little Rock, Ark.

Although health experts frequently advise people to reduce their cholesterol levels, doubts remain about whether it actually helps people live longer if they already have healthy hearts. Although the latest study was conducted exclusively on people who had suffered heart attacks, Buchwald said he believes the research should settle that question.

It found that lowering cholesterol saved lives among people whose hearts were still healthy because their heart attacks had caused minimal damage. Twenty-four percent of these people died during the 10 years after their cholesterol-lowering operations, compared with 39% in a comparison group who tried to lower their cholesterol through diet alone.

In the study, 421 people who recovered from heart attacks underwent the surgery, while a comparison group of 417 people was treated with diet alone. At the start of the study, their average cholesterol levels were 251. The surgery lowered their cholesterol 23%.

The mortality rate was not significantly lower for the entire surgery group, but it was lower for those with the healthiest hearts. The surgical patients also required less than half as many coronary bypass operations because of clogged heart arteries.

The surgery “has a role in the management of patients with high cholesterol who have had a heart attack,” Buchwald said. “It is eminently logical to extend all cholesterol-lowering therapy, including this, to patients with high cholesterol who have not had a heart attack.”