Angioplasty or bypass surgery?

For many people, choosing one or the other is a toss-up.

Angioplasty or bypass surgery? Which is best when cholesterol-laden plaque narrows a coronary artery and chokes off blood flow to part of the heart muscle?

There's no simple answer. It depends a lot on your situation: how many arteries are blocked, where the blockages are, your overall health, and your preferences. It also depends on how you define "best" "" most durable, shortest recovery, fewest complications, or longest survival.

At first glance, angioplasty with stent placement seems to be a clear winner. It requires a small nick in the groin, local anesthesia, an overnight hospital stay, and a relatively rapid recovery. In comparison, bypass surgery requires opening the chest, general anesthesia, a several-day hospital stay, and weeks of sometimes painful recovery. These differences are one reason why nearly 1.3 million angioplasties were performed in 2007 in the United States alone, compared with 470,000 bypass surgeries. On the other hand, surgery is the king of the hill when it comes to durability and freedom from chest pain. Far fewer people need a repeat procedure after bypass surgery than angioplasty.

Simplest cases

For an uncomplicated blockage in a single coronary artery, angioplasty is becoming the first choice for most cardiologists and their patients. It is quick, relatively painless, and has you back to your usual activities in a few days. A number of large studies show that survival after angioplasty is as good as after bypass surgery.

The convenience of angioplasty comes with a price. Up to one-quarter of people who have angioplasty must have it repeated, or have bypass surgery, within a few years. And anyone who gets a drug-eluting stent must take medicine for at least a year to prevent the formation of potentially deadly clots around the stent.

More complex problems

Bypass surgery was once thought to be the only solution for blockages in two or three coronary arteries, at the junction of two arteries, in a heart with poor pumping power in the left ventricle, or in an individual with diabetes or kidney disease. But even here, angioplasty is catching up. It's hard to be sure how comparable the two procedures are, since there are no data yet from head-to-head trials for such complex situations. But there are inklings from other sorts of information.

The latest comes from a review of data collected by the state of New York. It included all 17,000 bypass surgeries and angioplasties performed in 2003 and 2004 in the state's non-federal hospitals. Investigators compared deaths immediately after these procedures, deaths within 18 months, and heart attacks within 18 months. News reports about this work, which was published in the January 24, 2008 New England Journal of Medicine, bore headlines like "Surgery better than stents for multiple blockages." That isn't the whole story.

Bypass surgery was better, but not by much (see "Multivessel procedures"). An extra 1.6% to 2% of people in the bypass group were still alive and had not had a heart attack after 18 months. Of course, that small difference isn't anything to sneeze at when more than a million of these procedures are performed each year. The biggest difference between the two procedures was in the need for repeat procedures. Among those who initially underwent angioplasty, 30% needed a second procedure within 18 months, compared with 5% in the bypass group.

This study collected information from 2003 and 2004, when the use of drug-eluting stents was in full swing. So the results are relevant today. But the cardiologists and patients chose which procedure to have. This could skew the results in favor of bypass surgery because doctors sometimes suggest angioplasty for frail patients or those with conditions that might increase the chances of dying soon after any cardiovascular procedure.

Better answers to the angioplasty-or-bypass question should be coming in the next few years. At least three ongoing trials, dubbed FREEDOM, SYNTAX, and VA CARDS, are comparing the short-term and long-term effects of angioplasty and bypass surgery for multivessel or complex coronary artery disease.

Until then, the results of angioplasty and bypass surgery are close enough that you usually have a choice. And never hesitate to ask your doctor why he or she is recommending one over the other, or to seek a second opinion.

Multivessel procedures

In a "look back" study, bypass surgery was a tiny bit better than angioplasty for complex procedures.

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Bypass surgery

Angioplasty

Percent surviving to 18 months and free of heart attack

3-vessel blockage

96.0%

94.6%

2-vessel blockage

94.5%

92.5%

Percent needing a repeat procedure within 18 months

5.1%

30.6%

Do you really need a procedure?

If you are having a heart attack, then undergoing emergency angioplasty or bypass surgery is absolutely the best remedy. The same isn't true for mild chest pain brought on by physical activity (angina) or a narrowed coronary artery that doesn't cause any symptoms at all. Before hopping on the procedure train for these, consider the advantages of the medical approach: drugs to ease or prevent angina, to protect the heart and blood vessels, and perhaps to boost protective HDL cholesterol, along with exercise and healthful eating.

Medical therapy isn't really an option. It should be an integral part of life after angioplasty or bypass surgery. Angioplasty squashes a plaque, bypass surgery creates a detour around it, but only medical therapy fights atherosclerosis, the disease that causes plaque to form. Without it, plaque keeps growing.

For people with stable angina or a narrowed but silent coronary artery, medical therapy alone is as good as angioplasty. It avoids the small but very real risk of complications from angioplasty or bypass surgery. These can range from infection to stroke or even death. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial showed that adding angioplasty to state-of-the-art medical therapy was no better than medical therapy alone at preventing future heart attacks and extending life. The lesson from COURAGE is that angioplasty can be a choice, not a necessity, for treating stable angina.

The other big thing to think about is how you'll manage taking clopidogrel (Plavix) and aspirin every day for at least a year after getting a drug-eluting stent. These drugs are essential for preventing the sudden, and often deadly, formation of a clot on the stent. But they can be hard on the stomach or cause gastrointestinal bleeding, especially for people who also need to take a nonsteroidal anti-inflammatory drug like ibuprofen for joint pain. Moreover, some doctors don't want their patients to stop taking this combination long enough to have a hip or heart valve replaced, a gallbladder removed, or other surgery. Before agreeing to have angioplasty with a drug-eluting stent, make sure your doctor has a strategy for protecting the stent if you end up needing surgery down the road.