neil armstrongNeil Armstrong was a great American hero who: 
• flew 78 combat missions as a Korean War military pilot, 
• was a test pilot for new planes, and 
• was the 1966 spacecraft commander for Apollo 11, the first manned lunar mission.
On July 20, 1969, he became the first human to walk on the moon.  He later became a professor of aerospace engineering at the University of Cincinnati.  
In February 1991, at age 61, he suffered a heart attack while skiing with friends in Aspen, Colorado.  Twenty-one years later, in 2012, he died shortly after undergoing bypass heart surgery in Cincinnati, Ohio.  Seven years after his death, The New York Times published a detailed report of the confidential malpractice lawsuit that followed his death (The New York Times, July 23, 2019). 
Probable Malpractice
The wrongful death lawsuit brought up several concerns about his medical treatment:
• Armstrong was taken to a local suburban hospital to treat serious heart disease, rather than to an academic institution with highly experienced cardiologists, interns, residents, fellows, other faculty and medical students to look over the care of their patients.
• The doctors chose to perform immediate bypass surgery for a non-emergency situation that can often be managed just with medications and lifestyle changes. 
• Temporary wires were placed in his heart to regulate heartbeats (a common practice). The wires were later removed by a nurse.  While the wires were being removed, Armstrong’s heart started to bleed and his blood pressure dropped.
• At this point he was taken to the hospital’s catheterization laboratory, rather than to an operating room. There the doctors drained blood from Armstrong’s heart and then moved him to an operating room. He died one week later.
• Consulting doctors for the claimants' lawsuit felt that as soon as the patient started to bleed into his heart and his blood pressure dropped, he should have been taken to the operating room, not the catheterization laboratory. A sudden drop in blood pressure is a life-threatening sign. 
• Bypass surgery is almost never a procedure that has to be done immediately, yet the family was apparently not advised to seek second opinions or to take him to an academic hospital.
• The hospital settled for 6.2 million dollars, with the provision that information about Armstrong’s death and the lawsuit not be disclosed to the public.  The New York Times article notes that, "The legal settlement . . . illustrates the controversial but common practice of confidential settlements in medical malpractice and other liability cases, which protect reputations but hinder public accountability."

Who Needs Bypass Surgery or Stents?
Bypass heart surgery is a procedure that diverts the flow of blood around a blocked artery leading to your heart.   It is indicated when blood flow to the heart is blocked enough to cause symptoms or irregular heartbeats, and usually involves partial blockage of more than one artery.  This major surgery has many immediate surgical risks and complications but once the patient has recovered, the surgery does not cause increased risk for clots in the future. 
Stents are tubular devices placed inside a blood vessel to open previously blocked blood flow.  The indication for a stent is mainly to unblock a completely blocked artery leading to your heart and doctors have only about three hours from the start of the blockage to prevent the heart muscle from dying.  Stents may also help people with chest pain or irregular heartbeats that cannot be controlled by all other treatments and perhaps those in heart failure.  
The Bypass Procedure
Blood vessels are taken from another part of the body and used to bypass blocked arteries leading to the heart. Bypass heart surgery is indicated to increase blood flow to the heart when the doctor feels that symptoms are too severe to wait for medical treatment and lifestyle changes:
• heart failure,
• angina (heart pain) that cannot be controlled with medication,
• blocked blood vessels that need to be opened immediately, or
• when medical treatment is not likely to be effective, such as having three or more blocked arteries. Generally, bypass patients are less likely than stent patients to need repeat surgery (N Engl J Med, March 26, 2015;372:1204-1212).
A review of 11 randomized trials involving the follow-up of 11,518 patients with plaques in multiple arteries leading to their hearts showed that those who had bypass surgery were less likely to die than those who had stents (Lancet, Mar 10, 2018;391(10124):939-48).  The COURAGE research trial showed that patients with stable heart disease (no complete obstruction of blood flow to the heart) do just as well with medical treatment (drugs, exercise and a heart-healthy diet) as they do with bypass surgery (N Engl J Med, 2007, 356(15):1503-16). This has been confirmed by other studies (Lancet, 2009, 373(9667): p. 911-8). Sudden chest pain or shortness of breath can be signs of complete obstruction of blood flow to the heart muscle.
Too Many Stents?
An estimated two million people get coronary artery stents every year at a cost of more than 15 billion dollars.  Many heart specialists feel that stents should not be put into the heart arteries unless a person has virtually complete blockage of blood flow to the heart, a sign of impending death of heart muscle, or uncontrollable chest pain. Stents have not been shown to prevent heart attacks or strokes, probably because people with plaques in one artery often also have plaques in all of their coronary arteries.  Stents increase risk for future clots that can cause heart attacks and strokes, so people with stents usually must take anti-clotting medication for the rest of their lives.
Plaques accumulate over many years on the inner lining of arteries leading to the heart, but heart attacks are not caused by plaques that partially obstruct blood flow through a heart artery.  Heart muscle must get oxygen from the bloodstream 24 hours a day. A heart attack means that a part of the heart muscle dies when blood flow to part of the heart muscle is blocked completely for more than three hours. A heart attack occurs when a part of a plaque breaks off, the area bleeds and clots, and then the clot extends to block completely any flow of blood through that artery. Then the heart muscle has no source of oxygen and starts to die. If a cardiologist runs a tube into a completely blocked artery and opens the artery with a balloon, blood flows freely to the heart muscle and the heart muscle does not die. Then the cardiologist inserts a stent into the previously blocked artery to keep it from closing again and the cardiologist may have saved that person's life.  Stents can definitely save lives when they are placed within the first few hours after a person starts to suffer a heart attack. There is little good evidence to show that stents placed in heart arteries that are not completely blocked will decrease chest pain or prevent heart attacks. Too Many Stents 
Lessons from the Lawsuit on Neil Armstrong's Death
If you have any risk factors for heart attacks, it is never too early to do some advance planning and to make lifestyle changes.  Armstrong had plenty of warning; he had a first heart attack 21 years before his death.  
• Discuss any abnormal findings in your annual physical with your physician.  Make sure you understand the meaning of those that indicate heart attack risk (high blood pressure, high LDL cholesterol, high blood sugar and so forth), and how to bring them under control.  If you have several heart attack risk factors that do not respond to your lifestyle change efforts, ask for a referral to a cardiologist.
• Anyone with symptoms of heart disease should be managed by a competent cardiologist, preferably one who is willing to talk with you about medications and other decisions, and can motivate you to make any needed lifestyle changes.
• Give some thought to where you will go if you need urgent care, and make sure your spouse, family and/or friends know of your wishes. 
• Keep yourself educated on your condition and up to date on the best treatment options.  You are your own most important advocate for your health care. 
August 5, 1930 – August 25, 2012