Is Bypass Truly Better than Stenting?

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Is Bypass Truly Better than Stenting?

Feb. 27, 2009
In people with severely blocked heart arteries, bypass surgery produced better results than angioplasty plus the implantation of a stent, and thus "remains the standard of care" in such cases, according to an international study.

But that assessment is disputed by one of the cardiologists involved in the study and an expert who wrote an accompanying editorial.

The benefits and disadvantages of both procedures are so evenly balanced, they said, that a decision on which should be used can be left in most cases to the person being treated.

The study, which was released Wednesday by the New England Journal of Medicine for its March 5 issue, included 1,800 people who had blockages of the left main coronary artery or three major heart arteries. Half had bypass surgery, and the other half had what is formally called percutaneous coronary intervention (PCI) -- typically angioplasty -- combined with an implanted stent, a tiny mesh tube that props open the vessel to keep blood flowing.

During the next year, 17.8 percent of those who had the stent procedure had "major adverse cardiac or cerebrovascular events," compared with 12.4 percent of those who had bypass surgery.

That demonstrated the superiority of surgery, the report said.

"But the important point is to read the fine print," said Dr. David R. Holmes Jr., professor of medicine at the Mayo Clinic Graduate School of Medicine, and one of the physicians involved in the study.

The death rate and occurrence of major coronary events such as heart attacks were the same in both groups, Holmes noted. The only major difference was in the need for repeat artery-opening procedures: 13.5 percent in the stenting group, 5.9 percent in the bypass group. There was a significantly higher risk of stroke in the bypass group -- 2.2 percent vs. 0.6 percent in the PCI group.

But the finding gives people who want to avoid surgery a viable option, "if they accept the possible need for more future procedures," Holmes said.

Until now, "patients in a study like this would have been told that the treatment of choice was bypass surgery, and there wasn't any good data to make a decision because it hadn't been studied in any rigorous way," he said. "This study looks at the most complex group of patients with the most extensive disease that has ever been looked at."

With the study results in hand, Holmes said, "the physician can present the data, but the patient is the one who can make the choice."

That's a course that many physicians might choose, said Dr. L. David Hillis, chairman of the department of medicine at the University of Texas Health Science Center in San Antonio, and co-author of the editorial.

"I think it's dealer's choice," he said. "I present the patient with two options. Some choose one, and some choose the other."

Some people are so fearful of the possible problems of bypass surgery that they will choose the stenting procedure despite the increased chance that they might need a second procedure in the year ahead, Hillis said. Others will opt for the certainty of surgery.

However, there are cases in which the decision has to be made by the doctor, he said. People who are unable or unwilling to take the clot-preventing medications, such as aspirin or Plavix, would not be suitable for stenting and "should be strongly encouraged to have surgery," Hillis said. "Then there are patients who for some reason have another disease entity that makes surgery a risk -- a bad lung condition, for example." Such conditions are found in 5 to 10 percent of cases, he said.

But generally, Hillis said, many physicians will let the patient choose. "I haven't taken a poll, but I think most would sit down and present the options to the patients."

Another report in the same issue of the journal affirmed the finding of a major study done two years ago that drug therapy was as effective alone as with stenting for people treated for heart attacks days or weeks after they occurred.

The new study, by physicians at Duke University, found that stenting did produce some temporary improvement in the quality of life but that the long-term benefits did not differ from those of drug treatment alone.

SOURCES: David R. Holmes Jr., M.D., professor of medicine, Mayo Clinic Graduate School of Medicine, Rochester, Minn.; L. Davis Hillis, M.D., chairman, department of medicine, University of Texas Health Science Center, San Antonio, Texas; March 5, 2009, New England Journal of Medicine