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Surgery Beats Balloon for Heart Disease

Surgery patients less likely to die or need repeat procedures, research finds

FRIDAY, Sept. 27, 2002 (HealthDayNews) -- Patients who have bypass surgery for blocked coronary arteries are less likely to die and less likely to need a repeat procedure than are those who get angioplasty.

That's the finding of a study that is published in tomorrow's issue of The Lancet.

However, cardiology experts, including one of the investigators from the 53 European and Canadian centers involved in the study, say angioplasty techniques are evolving so rapidly that the results of the study, which enrolled patients from 1996 to 1999, may already be out of date.

Researchers randomly assigned 988 patients with coronary artery disease, average age 61, to either bypass surgery or angioplasty. Angioplasty involves inflating a balloon inside an artery to keep it open, and the procedure for the study also included inserting a stent, which helps keep the vessel open. For the bypass surgery, a healthy vessel was harvested from another part of the body to replace a clogged vessel or vessels around the heart.

After an average of two years of follow-up, about 20 percent of those who had the balloon-and-stent technique needed additional treatment to keep the vessel open, compared to 6 percent of the bypass patients. Only 2 percent of the bypass patients died, compared to 5 percent of the balloon and stent patients, a finding that lead the investigators to call for more research on the apparent reduced mortality of bypass surgery.

However, the researchers note, not all the deaths were caused by cardiac or other vascular causes, the researchers note. Of the 22 balloon patient deaths, 11 were definitely a result of cardiac or vascular causes. Of the eight bypass surgery deaths, five were blamed on cardiac or other vascular causes.

But those patients who underwent the balloon technique did have a lower heart attack rate. Roughly 5 percent of the balloon patients and 8 percent of the surgery patients had heart attacks during the follow-up.

A consortium of stent manufacturers funded the study.

While cardiology experts praise the latest work, many of them -- especially those who work as "interventional cardiologists" and favor less invasive techniques -- say it's not the last word.

"It's a well-done study," says Dr. Jesse Currier, an associate director of the Adult Cardiac Catheterization Laboratory at the University of California at Los Angeles. Although the balloon group needed more repeat interventions than the surgery group did, Currier says the need for repeat procedures with the balloon technique is less than it was years ago, before stents were commonly used.

"The only concern I have for this study is there were more deaths in the angioplasty group," Currier says. Like other experts, he says that result needs more study.

"It shows the gap between angioplasty and stenting is narrowing," Currier says. However, he notes that even if a patient is a good candidate for the balloon procedure, some opt for surgery because they don't want to face the prospect of repeat procedures.

"Most of the time, the need for a repeat angioplasty occurs within six to nine months," Currier says. Bypass grafts typically last a decade or even longer.

In a commentary accompanying the piece, cardiology experts William O'Neill and Cindy Grines from the William Beaumont Hospital in Royal Oak, Mich., note that surgery provides more complete resolution for the clogged vessels, but as the balloon technique continues to improve, "the gap in choices will continue to narrow."

One of the study investigators, Dr. Merril Knudtson, director of interventional cardiology at the University of Calgary, says that while the study overall seems to favor surgery, developments in stents and the balloon technique may soon change the picture.

Newer stents are coated with drugs that are released after the device is in place, reducing the risk of vessel closure, he says.

"The drug-eluting stents seem to have recurrence rates that are in the 5 [percent] to 8 percent range," he says, which would make them comparable to surgery.

What To Do

For more information on angioplasty and stents, visit the American Heart Association. The National Heart, Lung, and Blood Institute has more on coronary heart disease.

SOURCES: Merril Knudtson, M.D, professor of medicine, and director, interventional cardiology, University of Calgary, Calgary, Canada; Jesse Currier, M.D., associate professor of medicine, David Geffen School of Medicine, University of California at Los Angeles, and associate director, UCLA Adult Cardiac Catheterization Laboratory, Los Angeles; Sept. 28, 2002, The Lancet
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