University of Virginia Health System

Surgery Tops Stents for Multiple Heart Blockages

Bypass surgery provides a lower risk of heart attacks and death than stents for people with blockages of at least two heart arteries, says a report in the New England Journal of Medicine (NEJM).

"But there isn't any other study right now that is better than this," he says. "Physicians need to inform patients about these results and need to engage in a dialogue that includes these findings to determine what is the proper treatment for multi-vessel disease."

John A. Kern, M.D., Associate Professor of Surgery at the University of Virginia Health System, says area cardiologists are generally having good discussions with their patients about the benefits of surgery for blockages of multiple heart arteries.

"So I think here at UVA, most patients with two- or three-vessel disease are probably being referred for surgery to begin with," he says. "It's nice to see data that backs that up."

Further Studies Will Define State-of-the-Art Treatments

Hannan studied the outcomes of more than 17,400 procedures for people with multiple blocked coronary arteries.

The outcomes were consistently better in an 18-month follow up for bypass surgery than for the artery-opening procedure called angioplasty followed by insertion of a drug-coated tube known as a stent.

For example, 92.1 percent of patients who had surgery for three blocked arteries had no heart attacks and were alive, compared with 89.7 percent of patients who got stents.

For patients with two blocked arteries, 94.5 percent of surgical patients had no heart attacks and were alives, compared with 92.5 percent for stent implants.

The study was not a randomized, controlled trial, which is regarded as the gold standard for medical research.

It was observational, meaning that the researchers simply recorded what happened in medical practice rather than trying to control all the factors involved in choosing a treatment.

"But the randomized trials done in the past have not necessarily been better," explains Hannan. "They were restricted to patients who were not very sick, and they also did not recognize that when you compare two treatments, some patients might not prefer the one that is more invasive."

Surgery is more invasive than angioplasty, because it requires the chest to be cut open. Angioplasty is done by threading a flexible tube called a catheter through a blood vessel into the heart.

One shortcoming of the study is the relatively short follow-up period of 18 months, says Dr. Joseph P. Carrozza of Harvard Medical School, who wrote an editorial accompanying the study.

"One would like to see patients followed for up to five years," says Carrozza. "There is nothing in this study that makes us feel surgery is the treatment of choice for patients with multi-vessel disease."

Such a verdict will have to wait on the results of several randomized trials now under way, says Carrozza.

"This is just one piece of evidence we have right now before we get the final word," he explains.

But he adds that this is the first really large study to look at this issue and should be considered by doctors and heart patients requiring treatment for blocked coronary arteries.

UVA's Kern says that stents are preferable to surgery when patients have enough additional medical problems to make surgery very risky. 

Types of Stents Compared in Second Study

Another report in the same issue of the journal compared the safety of bare-metal to drug-coated stents for so-called "off-label" uses - implants for conditions where there is no formal government approval.

About half of all stent implants are for such conditions.

Questions have been raised about the safety of drug-coated stents in off-label conditions, said a report by a group led by Dr. Oscar C. Marroquin of the University of Pittsburgh.

But the study of 6,551 cases found a lower rate of complications and no increased risk of death or heart attack for drug-coated stents compared with the bare-metal stents.

"These findings support the use of drug-eluting stents for off-label indications," the researchers write.

That report comes on the heels of a study of off-label use of a different kind of stent, developed for use against bile-duct obstructions in cancer patients.

More than 1 million patients received stents for off-label conditions between 2003 and 2006, according to a report by Dr. William Maisel, director of the Medical Safety Device Institute at Beth Israel Deaconess Medical Center.

Some 1,000 malfunctions of the devices were reported, with 81 percent in off-label uses.

Learn more about coronary artery disease and heart health - and UVA's Heart and Vascular Center - at www.uvahealth.com.

Women can learn more about their unique risks for heart disease - and how to better manage those risks - through Live Red, UVA's new heart-health initiative. You'll learn how heart-attack symptoms can be different for women than for men, and you can take an online risk assessment to learn your personal heart disease risk factors.

There, you can sign up for Club Red, our free heart-healthy club for women. Benefits include tips from UVA healthcare providers and a gift package to help you live red in style.

Always consult your physician for more information.