titioners in the Leicester area and the local health authority might ... of the patients and 90% are out of hospital within ... North Western Regional Health Authority,.
He and many others might never have taken to smoking if there had not been a war. Nothing was known about a link with any disease then. Not even the medical profession knew-except the first few who suspected a link with lung cancer, and even that was not clear for a long time afterwards. All these survivors of the war are now at an age when they may need bypass surgery. They smoked through no fault of their own, and nobody had knowledge of possible consequences. They were encouraged to smoke and given easy access to cigarettes. They gave five years of their young lives to the defence of Britain. Are our surgeons, most of whom will be much younger, and who can have no personal experience of those days, now to deny these men treatment for physical conditions possibly engendered by their years of smoking? I hope not. KATrHLEEN ABRAHAM
Caton, Lancaster LA2 9HS
Trial ofthrombolysis favours smokers EDITOR,-Recently Barbash et al analysed the results of the international tissue plasminogen activator/streptokinase mortality trial.' Having compared the results in non-smokers, ex-smokers, and active smokers, they report that in nonsmokers the mortality in hospital and the mortality at six months were 12-8% and 17-6% respectively; in smokers the figures were 5-4% and 7.8% respectively. The rate of reinfarction in hospital was 4-7% in non-smokers and 2/7% in smokers. Non-smokers also had a higher incidence of shock, stroke, and bleeding in hospital. The ex-smokers had results between these, and among the smokers there was a "non-significant trend for mortality to decrease with increased number of cigarettes smoked." On the basis of these findings, would M J Underwood and J S Bailey advocate non-treatment of non-smokers who suffer a myocardial infarct until they take up smoking?2 A BLESOVSKY
I Underwood MJ, Bailey JS, Shiu M, Higgs R, Garfield J. Should
smokers be offered coronarv bypass surgery? BMJ 1993;306: 1047-50. (17 April.)
Brodick, Isle of Arran KA27 8AW I Barbash GI, White HD, Modan M, Diaz R, Hampton JR, Heikkila J, et al. Significance of smoking in patients receiving thrombolytic therapy for acute myocardial infarction. Evidence gleaned from the intemational tissue plasminogen
Send us your patients who smoke
activator/streptokinase mortality trial. CirculatiOn 1993;87:
EDITOR,-M J Underwood and J S Bailey state that they do not consider patients who smoke to be candidates for cardiac surgery.' There must, therefore, be many patients in the Leicester area who have been refused cardiac surgery. We suggest that fundholding general practitioners in the Leicester area and the local health authority might send the patients refused by Underwood and Bailey to us. At the Oxford Heart Centre we ask patients to stop smoking for six weeks before cardiac surgery. Few patients are non-compliant, and as a result we have eliminated the need for intensive care postoperatively for most of the patients and 90% are out of hospital within
six days. We maintain a policy of operating on patients on clinical medical grounds regardless of socioeconomic status, age, weight, or social habit. Call us old fashioned if you like, but we prefer to remain
doctors treating patients. M SINCLAIR R PILLAI S WESTABY
Department of Cardiac Surgery, Oxford Heart Centre,
John Radcliffe Hospital, Oxford OX3 9DU
53-8.
2 Underwood MJ, Bailey JS, Shiu M, Higgs R, Garfield J. Should smokers be offered coronary bypass surgery? BM17 1993;306: 1047-50. (17 April.)
Rationed services should go to those who benefit EDITOR,-I congratulate the cardiac surgeons in Leicester who have had the courage to rationalise services to those patients who are most likely to benefit.' They have perhaps been foolhardy to put their necks on the block for the smoking lobby to indulge in a campaign of vilification against them. Politicians of all political parties speak with forked tongues when it comes to the nation's health. Time after time the commercial barons have put their personal profits before the long term health and wealth of the nation and people. I pray that the medical profession's dogged defiance against mercenary interests may long continue. The government and politicians ought to open their eyes and look at the overwhelming scientific evidence on the damage that tobacco smoking causes to smokers and, unfortunately, to non-smokers through passive smoking. VIJAY BANSAL
I Underwood MJ, Bailey JS, Shiu M, Higgs R, Garfield J. Should smokers be offered coronary bypass surgery? BMJ 1993;306: 1047-50. (17 April.)
BMA Mersey Regional Office, Liverpool L7 7BL 1 Underwood MJ, Bailey JS, Shiu M, Higgs R, Garfield J. Should smokers be offered coronary bypass surgery? BAM 1993;306: 1047-50. (17 April.)
artery surgery study has been published. This clearly shows that patients who continue to smoke after coronary artery surgery have more angina, are more likely to be unemployed, have greater limitation of physical activity, have more admissions to hospital, and have a decreased survival compared with non-smokers. This follow up emphasises the limitation of coronary artery bypass surgery in this subgroup of patients and, we believe, substantiates our assertion that M A Edgar comments on. We have not instigated any new "policy"2 in our unit. Our views merely represent the balance that needs to be achieved between risk and benefit when an operation is being considered for a particular patient. Patients are not "refused" surgery. They are advised of the increased risks, counselled by experts, and reviewed at appropriate intervals until the ratio of risk to benefit favours an operation. In our experience patients are more than willing to make a determined effort to stop smoking once the risks have been fully explained. It is interesting that the experience of the Oxford Heart Centre is similar to ours and that it too ensures that patients stop smoking before surgery. This attitude represents not "contempt for the patient" or a "latent resentment"' but a concern that he or she should receive the best possible treatment we can offer. We have recently published a study into the detrimental psychological effects experienced by patients awaiting coronary artery surgery and a plea they should be treated with a more holistic approach'-a plea hardly in keeping with "the authoritarian medical persona."+ We also believe that the suggestion that clinical decision making is different in the private sector merely trivialises what is an important issue.", There is no evidence to substantiate this comment, and, surely, with the increase in postoperative complications that we documented, a smoker is the last patient a cardiac surgeon wants languishing in the private wards. A Blesovsky's comments merit consideration, but a detailed discussion is beyond the scope of this letter. The results of the international tissue plasminogen activator/streptokinase mortality trial are indeed as Blesovsky quotes, but they are at variance with those of other studies.' The smokers alluded to were younger and had more benign profiles of risk factors and health status than the non-smokers (who, incidently, were more likely to be female and therefore to have a worse prognosis after infarction). Care has to be taken, therefore, in interpreting these results, and a detailed analysis of the implications has been published.' This topic requires serious debate, particularly in the light of The Health of the Nation, a prime objective of which is to reduce the incidence of disease related to smoking. We look forward to future discussion and recommendations on how to approach this important issue, particularly in view of the limitations on available resources. MJ UNDERWOOD J S BAILEY
Unsubstantiated assertion EDITOR,-M J Underwood and J S Bailey provide an eloquent dissertation, backed up by 36 references, on the problems encountered by smokers who receive coronary bypass surgery.' I also note their comment on the current capacity for such bypass operations: "Treating [smokers] deprives patients who have never smoked or who have stopped smoking of more efficient and effective surgery." Though this may be the case, the assertion is not self evident from the arguments presented in the article. It is also unreferenced. Is that because it is one assertion too far? M A EDGAR
North Western Regional Health Authority, Manchester M60 7LP 1 Underwood MJ, Bailey JS, Shiu M, Higgs R, Garfield J. Should smokers be offered coronary bypass surgery? BMJ 1993;306: 1047-50. (17 April.)
BMJ VOLUME 307
10 JULY1993
Authors' reply
Department of Cardiothoracic Surgery, Groby Road Hospital, Leicester LE3 9QE
EDITOR,-Certain misunderstandings seem to have resulted from our article; presumably because, of necessity, it was brief and didactic. We stated quite clearly that subjecting patients who continue to smoke and for whom the only indication for operation is relief of angina to the increased risks of surgery in the face of a remediable cause is not justified. Such patients obviously do not include those who may be in "urgent need of intervention"' or those who are "threatened by death because of their disease."2 This is an important distinction. We thought that we had presented a factual argument that clearly documented the limitations of vascular operations in smokers; it certainly was not based "on prejudice."' Since our article was written the 10 year follow up from the coronary
I Bhattacharya S. Access to heart surgery for smokers. BMJ 1993;306:1409. (22 May.) 2 Zolese G. Access to surgery for smokers. BMJ 1993;306:1408. (22 May.) 3 Mamode N. Access to surgery for smokers. BMJ 1993;306:1408. (22 May.) 4 Cavender JB, Rogers MJ, Fisher LD, Gersh BJ, Coggin CJ, Myers WO. Effects of smoking on survival and morbidity in patients randomised to medical or surgical therapy in coronary artery surgery study (CASS): 10 year follow up. JACC 1 992;20:287-94. 5 Underwood MJ, Firmin RK, Jehu D. Aspects of psychological and social morbiditv in patients awaiting coronary artery bypass grafting. BrHeartJ 1993;69:382-4. 6 Khalid MI. Access to heart surgery for smokers. BMJ 1993;306: 1408. (22 May.) 7 Jafri SM, Tilley BC, Peters R, Schultz LR, Goldstein S. Effects of cigarette smoking and propranolol in survivors of acute myocardial infarction. An I Cardiol 1990;65:271-6. 8 Ockene IS, Ockene JK. Smoking after acute myocardial infarction: a good thing? Circulation 1993;87:297-9.
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