When Bypass Beats Angioplasty
For Complex Heart Disease, Surgery Often Best Treatment Choice
Jan 23, 2008 -- Patients with complex heart disease are less likely to
die or have a heart attack if treated with bypass surgery rather than
angioplasty and stenting.
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
- 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
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
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.