Older patients with clogged heart arteries may have a little lower death risk over time if they get bypass operations instead of angioplasty and stents to fix the problem, new research suggests.
It's not the kind of study that gives conclusive evidence, but doctors say it gives a "real world" look at how people fare in ordinary practice. As such, it could tip the balance toward surgery for patients considering the choice, especially because research already shows bypass gives a better and longer lasting result for people with multiple blockages.
In a bypass operation, doctors move healthy blood vessels from other parts of the body to detour around clogged arteries supplying blood to the heart. Angioplasty treats the problem via a tube pushed through a blood vessel. A tiny balloon is inflated to flatten the clog and a mesh scaffold, a stent, is placed to prop the artery open.
Researchers compared these approaches using records on 190,000 Medicare patients with two or three blockages _ the largest study ever of this issue. Death rates were similar one year after either treatment. But after four years, nearly 21 percent of the angioplasty patients had died versus about 16 percent of those who had bypass surgery.
Results were discussed Tuesday at an American College of Cardiology conference in Chicago and published online by the New England Journal of Medicine.
In the United States, more than a million operations or procedures are done each year to treat clogged arteries, and the study "provides comprehensive, large-scale, national data" to help doctors and patients decide which treatment is best, Dr. Susan Shurin said in a statement. She is acting director of the National Heart, Lung and Blood Institute, which sponsored the study.
Comparative effectiveness studies like this one are taking on greater importance as more attention turns to the cost of health care.
Researchers used databases kept by the American College of Cardiology Foundation and the Society of Thoracic Surgeons on 86,244 people who had bypass surgery and 103,549 others who had angioplasty between 2004 and 2007. They used fancy statistical adjustments to try to compensate for differences in the groups that might affect the results.
They found bypass to give a survival advantage even when they considered factors such as sex, race, age, and conditions like diabetes.
"Everything lines up" in favor of surgery, said study leader Dr. William Weintraub of Christiana Care Health System in Newark, Del. "We were frankly surprised by that."
Still, researchers say differences in the overall health of people who had surgery versus the less drastic procedure could account for some of the results. They say angioplasty remains a good and safe option for many people.
"You're not making a mistake if you still have angioplasty," especially if you have only one or two blockages, said Dr. Kirk Garratt of Lenox Hill Hospital in New York. He is a spokesman for the Society for Cardiac Angiography and Interventions, doctors who do angioplasties.
There are tests to help decide whether one treatment will be better than another, but "in general, doctors do it intuitively" based on how frail patients look, how easily they walk across the room, how firmly they shake your hand, said Dr. Harlan Krumholz, a health outcomes research specialist at Yale University.
The new study "nudges you a little closer" to favoring bypass, but because of the caveats, "in the end, it says it is a close call," he said.
The fact bypass gives a longer-lasting result is a selling point _ it means fewer repeat procedures, said Dr. Michael Crawford, chief of clinical cardiology at the University of California, San Francisco.
"Some patients buy that and want to go for the long term. Others, it's a tough sell," he said.
The real message is how safe both procedures are, said Dr. Vince Bufalino of Advocate Health Care, a 100-doctor cardiology group that serves 10 hospitals in the Chicago area.
"We still think a traditional operation is excellent" for people with multiple blockages, said Bufalino, an American Heart Association spokesman.
Heart meeting: http://www.cardiosource.org
New England Journal: http://www.nejm.org
Heart disease info: http://www.nhlbi.nih.gov/health/health-topics/topics/cad//
Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP