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For Complex Heart Disease, Surgery Often Best Treatment Choice
Daniel J. DeNoon
WebMD Health News
Reviewed By Louise Chang, MD
The finding comes from a comparison of patient outcomes after the two major types of treatment for blocked heart arteries. Patients received bypass surgery -- coronary artery bypass grafting or CABG -- or angioplasty with stenting, a nonsurgical technique in which arteries widened with a balloon catheter are propped open with mesh devices called stents.
The study looked only at patients who had two or three blocked arteries. It included all 17,400 patients treated from October 2003 through December 2004 for two or three blocked arteries in New York State.
The bottom line: Long-term outcomes were better after bypass surgery.
Edward L. Hannan, PhD, professor and associate dean for research at the University at Albany School of Public Health, Rensselaer, N.Y., and colleagues reported the findings in the Jan. 24 issue of The New England Journal of Medicine:
- Bypass patients with two blocked arteries were 29% less likely to die or suffer heart attacks than were angioplasty patients.
- Bypass patients with three blocked arteries were 25% less likely to die or suffer heart attacks than were angioplasty patients.
- Bypass patients were less likely to need a repeat procedure to open blocked arteries than were angioplasty patients.
But stent expert William O'Neill, MD, professor of medicine and cardiology at the University of Miami Miller School of Medicine, remains doubtful that bypass offers such a large survival advantage over angioplasty.
"You really do have to ask yourself why the doctors in this study chose one method over the other for these patients," O'Neill tells WebMD. "This study is not a randomized trial, and even though it has a large number of patients, it is difficult to remove the possibility of selection bias. There is a very large, multicenter, randomized clinical trial, the SYNTAX trial, which will be reported in Europe next summer. I would urge everyone to wait for those results."
Hannan says randomized trials have biases as well, as patients may not choose to participate if they fear being assigned to a highly invasive surgery.
Angioplasty/Stents Still a Good Option
The current study results are similar to earlier studies in which Hannan and colleagues compared bypass surgery to angioplasty. But those studies looked only at bare-metal stents. The current study is the first to compare bypass to angioplasty using newer drug-eluting stents, which are less likely to clog.
However, drug-eluting stents are more likely than bare-metal stents to cause blood clots. Patients who get these stents now receive aggressive anticlot treatment -- treatment that was not routine during the time of the Hannan study.
This might have biased the results in favor of bypass surgery, notes Joseph P. Carrozza, MD, of Beth Israel Deaconess Medical Center, in an editorial accompanying the study.
Even so, Carrozza says the new results "are a sobering reality check for those who hoped the benefits of drug elution would level the playing field between [bypass surgery] and stents for patients with multivessel disease."
Does this mean all patients with multiple blocked arteries should have bypass surgery? No, Hannan says.
"When we talk about two procedures like angioplasty and bypass surgery, there is a big difference," Hannan tells WebMD. "In bypass surgery your chest is sawed open. You spend time in the hospital, and you don't feel well for a long time. After angioplasty, you go back to work the next day and feel fine."
There are medical reasons, such as dementia, that rule out bypass surgery for some heart patients. And Hannan notes that while bypass surgery has better long-term results for many patients, the short-term results are worse than for angioplasty.
"One reason to choose angioplasty and stenting is if patients just prefer not to get very aggressive surgery that will discommode them for many months," he says. "And the short-term adverse-outcome rate for bypass -- including the in-hospital mortality rate -- that is higher than for angioplasty. So if you have a strong need to survive for a short period of time, like a big event you want to be around for, that contraindicates bypass surgery."
Hannan says the next step for researchers is to find out whether patients with particular conditions do better with bypass surgery or with angioplasty.
What Heart Patients Need to Know
Because researchers and doctors continue to improve both bypass surgery and angioplasty, Hannan says there will never be a one-size-fits-all answer to which technique is best. For this reason, he strongly suggests that patients discuss all of their options with both an interventional cardiologist and a surgeon.
Before either bypass surgery or angioplasty, cardiologists use a heart catheter to look at the conditions of a patient's arteries. Since the catheter already is in place, some cardiologists may choose to perform an angioplasty at that time.
"I would say you need to consult with a multidisciplinary team, including a cardiologist and a surgeon, starting with the cardiologist," Hannan advises. "When you engage in dialogue with this doctor, be sure that person is aware of the most recent studies, and that these studies are part of the decision-making process. But you need to take into account what is the typical nature of the recovery period, what procedures will be done and when, and what are the contraindications of each procedure."
O'Neill says that if patients are offered the option of either bypass surgery or angioplasty, it means that they have an excellent chance of long-term survival with either procedure.
"Bypass provides more effective long-term relief in multivessel cases," O'Neill says. "In the Hannan study, 5% of patients who underwent bypass needed a [a second procedure] compared to 30% of the angioplasty patients. So if patients don't want to come back, they need a bypass. If inconvenience, invasive surgery, and length of recuperation come into play, then patients may prefer angioplasty."
SOURCES: Hannan, E.L. The New England Journal of Medicine, Jan 24, 2008; vol: 358 pp. 331-341. Carrozza, J.P. The New England Journal of Medicine, Jan 24, 2008; vol: 358 pp. 405-407. Edward L. Hannan PhD, professor and associate dean for research, University at Albany, State University of New York, Rensselaer, N.Y. William O'Neill, MD, executive dean for clinical affairs and professor of medicine and cardiology, University of Miami Miller School of Medicine.
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