For Heart Patients, Bypass Might be Best

Heart patients with two or more blocked arteries live longer if they have bypass surgery than if they have their arteries cleared out with angioplasty and propped open with wire-mesh devices called stents, a major study reports Thursday.

Doctors say the research could have profound implications for heart patients, because twice as many now have angioplasty to avoid the trauma of bypass surgery. That’s a dramatic reversal from just a decade ago, when slightly more than a quarter of patients had angioplasty.

The study, which involved almost 60,000 patients treated from 1997 to 2000, offers the first long-term comparison of death rates for the two procedures. It found that patients were 33% to 56% more likely to die after angioplasty and stenting than after bypass surgery, report Edward Hannan of the State University of New York in Albany and colleagues.

Hannan says the analysis suggests that in just three years there were up to 540 “excess deaths” that might have been avoided if angioplasty and stent patients had had bypass surgery instead.

The results, which are published in Thursday’s New England Journal of Medicine, reflect real-life experience and not tightly controlled clinical trials. Only four prior studies compared the relative outcomes for the two procedures, and they yielded mixed results.

“This is an unexpected finding,” says Timothy Gardner, medical director of the heart and vascular center at Christiana Health Care System in Wilmington, Del., who wasn’t involved in the study. “The only thing I can think of is that surgery offers a benefit that we haven’t picked up on in randomized trials.”

Newer stents made with drug coatings could prevent tissue from growing back and clogging arteries again — a common problem with angioplasty that forces patients to have repeat procedures — but they probably would not affect death rates, Gardner says.

Hannan’s team analyzed data from 37,212 bypass patients and 22,102 angioplasty patients in New York state heart registries. Within three years of the procedure, patients who had angioplasty along with insertion of a stent consistently had higher death rates than those who had bypass surgery. In the sickest group of patients, for instance, the death rate was 15.6% for those who had angioplasty vs. 10.7% for those who had bypass surgery.

“What is new is the impressive advantage of surgery,” Bernard Gersh and Robert Frye of the Mayo Clinic in Rochester, Minn., say in an editorial in the journal. They add that “surgery may be superior in a larger group of patients than initially considered.”

In 2002, U.S. doctors performed 1.2 million angioplasties, about half with stents. Surgeons performed about 515,000 bypasses, according to the latest American Heart Association statistics.