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Heart Bypass Surgery Vs. Angioplasty Depends on Age, Diabetes

Posted: Saturday, April 07, 2007

What type of life-saving heart operation you should undergo — bypass surgery or angioplasty — largely depends on your age and whether you have diabetes, according to the largest-ever assessment of the two rival procedures. Stanford University researchers found significantly lower death rates among patients….

Though there's been little definitive information comparing the two, Americans have increasingly preferred angioplasty, which is considered less invasive. However, the new findings suggest that bypass might be the better method for diabetics and the elderly.

Stanford University researchers found significantly lower death rates among patients over 65 or diabetic who had bypass surgery. Those 55 and younger, however, fared slightly better after angioplasty.

"You can 'personalize' medicine with very simple clinical measures,'' said lead investigator Mark Hlatky, professor of health research and policy and of cardiovascular medicine at Stanford. "Simple information — Do you have diabetes? How old are you? — is a powerful predictor of outcome.''

The findings could have wide repercussions. Because of soaring rates of coronary artery disease, Americans now average nearly 250,000 bypass surgeries and more than 660,000 angioplasty procedures annually, totaling more than $100 billion in medical costs.

The report's timing coincides with the Obama administration's push to compare different health treatments, from drugs to devices to surgeries. The government hopes the information will help doctors select the most effective methods and drive down health care costs.

The study's conclusions are based on a vast compilation of the life-or-death results from the world's major clinical trials of heart disease treatment. Scouring the globe, the team compiled data from more than 8,000 patients — virtually every patient in the world with multivessel coronary disease enrolled in a clinical trial of bypass surgery and angioplasty.

Typically, studies can only say if a procedure helps an overall group. But averaging such results obscures critical differences among patients.  By pooling so much data in the Stanford study, "It was possible to 'drill down,' parsing the data in a number of ways to tease out the differences," Hlatky said.

For patients with diabetes, the team found that the death rate after five years was 12 percent for those who had bypass surgery, compared with 20 percent for angioplasty. For patients older than 65, the death rate was 11 percent for those who had bypass, compared with 15 percent for those who had angioplasty.

For patients younger than 55, however, the death rate was 5.5 percent among those who had bypass surgery, compared to 5 percent for those who had angioplasty. For those ages 55 to 64, bypass surgery patients had an 8 percent death rate compared to 9 percent among angioplasty patients.

There was no significant difference between men and women, racial or ethnic groups, or people who had two or three clogged vessels. Both approaches aim to prevent heart attack. In bypass surgery, blood vessels from elsewhere in the body are used to create detours around blockages. In angioplasty, a tiny balloon is snaked through blood vessels to flatten the plaque against the vessel walls, preventing blockage. In most cases, a stent is placed to keep the artery from squeezing shut again.

Although bypass surgery is a somewhat more expensive procedure and carries some short-term risk, "That extra risk is worth it, in the long run, for the right patients,'' Hlatky said.

Scientists do not know why there is such variation in the outcomes of these two groups of patients. That could be the subject of future research, he said.

The study is a powerful example of the "comparative effectiveness research" for which the Obama administration recently allocated $1.1 billion from the economic stimulus package. By finding the best treatments, this approach aims to reduce dangerous care and perhaps rein in health care costs, which consume nearly 18 percent of the gross domestic product.

Most Americans wouldn't buy a toaster without first comparing products, but such assessments have been difficult when it comes to life-saving procedures such as heart treatment. That's because research has rarely matched up dueling treatments. The traditional approach is to determine whether treatment works better than no treatment.

Kaiser, some state Medicaid programs, the Veterans Health Administration and an increasing number of private health plans are seeking ways to steer patients to the most appropriate treatment.

"This is the kind of research we're hoping to have more of so that clinicians and policymakers and patients can make informed decisions," said Dr. Douglas K. Owens, senior investigator at the Veterans Affairs Palo Alto Health Care System and professor of medicine at Stanford, who was a co-author on the study.

Source: Diabetes In Control: The Lancet March 26, 2009

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