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Heart bypass surgery or stents? Depends on patient

By Genevra Pittman

NEW YORK (Reuters Health) - The average person with multiple diseased arteries in the heart does slightly better following coronary artery bypass surgery than after having stents inserted, a new study suggests, but the optimal procedure varies by patient.

Researchers found slightly more heart patients survived at least five years after bypass surgery - 74 percent, versus 72 percent of those who had a stenting procedure, known as angioplasty.

However, people who had no diabetes or heart failure and were non-smokers tended to have better outcomes with angioplasty than with more invasive surgery, the study team reported Monday in the Annals of Internal Medicine.

"It's good to say, ‘On average people do better with this drug or this procedure,'" said Dr. Mark Hlatky, a healthy policy and cardiovascular medicine researcher at Stanford University in California.

"But if we could only target the people who would get the most benefit, we'd probably make better decisions and maybe save money," he told Reuters Health.

For their study, Hlatky and his colleagues tracked the records of 105,156 people on Medicare, the government health insurance program for the elderly, who had bypass surgery or received stents between 1992 and 2008. Patients from each treatment group were matched by age and the year they had their procedure.

The researchers calculated the average patient lived 19 days longer after bypass surgery than stenting. People with diabetes, heart failure and peripheral artery disease, as well as those who smoked, were especially likely to benefit from bypass surgery.

But the rest of heart patients - as many as 41 percent - were predicted to do better after angioplasty, they found.

Bypass surgery involves grafting a healthy blood vessel around a blocked one, so blood "bypasses" the unhealthy vessel. For a stent procedure, a small mesh tube is inserted into the blood vessel after it's opened with a balloon-tipped catheter.

The results are consistent with other recent research suggesting people with diabetes and multiple clogged arteries fare better after undergoing bypass surgery than after receiving drug-coated stents (see Reuters story of November 4, 2012 here: http://reut.rs/VMojN5 ).

"The first question is whether you need something done at all, (or) whether drugs alone are enough," Hlatky said. "The second questions is, once you think you do need to go ahead and drug therapy is not enough - either because symptoms are too bad or the patient is high-risk - then you can decide between bypass surgery and angioplasty."

For people who have only one clogged vessel, angioplasty is typically fine, Hlatky said.

"On the other end if there's very, very severe coronary disease in lots of places, most of the time patients go straight to surgery," he added.

It's in the middle where patients and doctors can use studies like this one to make more informed decisions about what treatment might be best for them, Hlatky said.

According to the Healthcare Blue Book, bypass surgery runs for about $64,000, including the hospital stay. Because angioplasty requires fewer days in the hospital, it typically costs less than half that.

SOURCE: http://bit.ly/MnBiCA Annals of Internal Medicine, online April 22, 2013.

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