Survival rates virtually the same, but some people may prefer one option over the other
TUESDAY, Oct. 16 (HealthDay News) -- Someone with "mid-range" -- or intermediate -- coronary artery disease can use a new review of previous studies to help decide between angioplasty to open blocked arteries or bypass surgery to route new vessels around them, cardiologists say.
The long-term safety of the two procedures is just about the same, said study senior author Dr. Mark Hlatky, professor of health research and policy and cardiovascular medicine at Stanford University School of Medicine. Results for almost 10,000 patients from 23 clinical trials in the United States and Europe showed 98.2 percent survival for bypass surgery and 98.9 percent for angioplasty.
"But some people don't like the idea of major surgery and might want angioplasty," said Hlatky. "Others may want a more definitive treatment, with surgery more likely to relieve angina [chest pain] over a long period of time."
There was a lower chance of needing a repeat procedure for those who had surgery. Just under 10 percent of bypass patients had repeat procedures within five years, compared to 46.1 percent of those who had angioplasty without an implanted stent and 40.1 percent of those who had angioplasty with a stent.
But the reduction in repeat procedures came at the cost of increased risk of stroke. The stroke rate was 1.2 percent for those receiving bypass surgery versus 0.6 percent following angioplasty.
That increased stroke risk might make the difference for some people, said Dr. Deepak Bhatt, associate director of the Cleveland Clinic Cardiovascular Coordinating Center, since "many people would rather take the inconvenience of coming back rather than a higher risk of stroke."
Studies measuring quality of life found it was better for the three years following bypass surgery as compared to angioplasty. The difference disappeared after three years.
The point of the new study was to "give the full picture so that the patient and physician can come to the best decision about it," Hlatky said.
One important finding was that the overall survival rates for the two procedures were the same for people with diabetes. One previous study had found a significantly higher death rate for diabetics who had angioplasty, a result that immediately became controversial. The new study lessens the controversy but does not eliminate it entirely, Hlatky said.
"We were kind of surprised by that result," Hlatky said. "No one had sat down and put all the data together. But even in this analysis, the number of such patients was fairly small. The issue will be decided by ongoing trials for patients with diabetes."
A decision about angioplasty versus bypass surgery is always easier to make outside the middle range of coronary artery disease looked at in these trials, both Bhatt and Hlatky said. "For high-risk coronary artery syndromes, revascularization [surgery] in general is the right thing to do," Bhatt said.
And angioplasty would be the procedure of choice for those whose condition could no longer be managed with drug therapy, Hlatky said. "We reviewed data from people in the intermediate zone of coronary disease," he said.
The analysis did not include angioplasties in which drug-coated stents, introduced several years ago, were used, rather than bare-metal stents. Use of the newer stents should not change the picture dramatically, Hlatky said.
Coronary artery disease and its treatments are described by the U.S. National Institutes of Health.
SOURCES: Mark Hlatky, M.D., professor of health research and policy, Stanford University School of Medicine, Stanford, Calif.; Deepak Bhatt, M.D., associate director, Cleveland Clinic Cardiovascular Coordinaing Center; Oct. 16, 2007, Annals of Internal Medicine
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