Heart bypass underused, study says

Tens or even hundreds of thousands of Americans are having coronary artery angioplasty and stenting every year when they should be having bypass grafts, and the result is an extra 5,000 or more deaths annually, researchers said Sunday.

Patients and cardiologists frequently prefer angioplasty and the insertion of a stent to keep arteries open because it is quicker and easier, and patients go home sooner and return to work more quickly.

But new data from a major European-American study on more than 1,800 patients show that three years after the procedure, those who got stents were 28 percent more likely to suffer a major event, such as a heart attack or stroke, and 46 percent more likely to require a repeat procedure to reopen arteries. They were 22 percent more likely to die.

“This is one of the strongest studies yet demonstrating that, in advanced coronary disease, bypass has a real patient advantage,” said Dr. Robert Guyton, chief of cardiothoracic surgery at the Emory University School of Medicine, who was not involved in the study. “This will change practice. It may not reverse some of the use of stenting, but it is certainly going to slow it down and make people think. Stenting is a little bit easier on you and the return to work is quicker. But the benefits of surgery are more enduring and tend to emerge as time goes by.”

Coronary-artery bypass grafts, commonly called CABG, were the first treatment for blocked arteries. A blood vessel removed from elsewhere in the body is used to bypass the blocked area, providing a new channel for blood to flow to the heart.

Hospital stays generally last five or six days, and the patient can return to work after a few weeks.

In recent years, however, cardiologists have turned to balloon angioplasty, in which a catheter is threaded through a blood vessel in the groin to reach the blockage and a balloon is inflated at the site to compress the plaque. Originally, that was all that was done. Then physicians began inserting bare-metal stents, devices that hold the artery open. Hospital stays are typically overnight, and the patient can return to work after a couple of days.

The new study, reported Sunday at a Geneva meeting of the European Association for Cardio-Thoracic Surgery, is the first large trial to compare stenting and CABG directly. Called SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery), the trial enrolled 1,800 patients at 85 centers in Europe and the United States.

Patients were randomized to receive either angioplasty with stenting or bypass.

Patients were considered to have mild disease if they had a single blocked artery. Their disease was considered moderate or severe if they had a blockage in the left main artery plus blockage in one of the other three arteries, or if they had blockages in all three other arteries. They were also considered severe if they had very long blockages, arteries that were totally blocked, or “very tortuous, curvy arteries” that make angioplasty difficult, Mack said.

For patients with mild disease, the two procedures produced equivalent results, so angioplasty might be preferred because it is easier on the patient. But the differences were much more dramatic for those with more severe disease.