Open Heart Surgery vs. Angioplasty

1/6/97
CONTACT: Mike Goodkind (415) 725- or 723-6911,
or via e-mail at [email protected]

OPEN HEART SURGERY VS. ANGIOPLASTY: LONG-TERM BENEFITS WEIGHED

STANFORD -- A study of 934 patients may offer some guidance to heart disease patients, their doctors and even insurance companies facing a choice between open heart surgery and the less invasive procedure called balloon angioplasty.

The verdict: "I would now tend to recommend bypass surgery for patients with three blocked vessels, and angioplasty for patients with one blocked vessel," said the study's lead author, Dr. Mark A. Hlatky, professor of health research and policy at Stanford University School of Medicine. "They're both good procedures in the hands of experienced doctors," Hlatky said.

"In patients with two blocked vessels who can be treated with either angioplasty or surgery, the medical results are so close that how the patient feels about the two options should be given the most weight in the decision," Hlatky said.

"They're both good procedures in the hands of experienced doctors," he added. Yet there are differences that may affect patients individually, Hlatky said. "The chance of complete angina [chest pain from heart disease] relief and improvement in physical capacity is somewhat better with bypass surgery, but at the price of more initial discomfort, a longer hospital stay and longer recovery time."

Unlike earlier studies, which only measured the initial cost and short-term results of the two procedures, the new study followed patients for five years. "Angioplasty is much easier initially, but half the patients will eventually need a second angioplasty or bypass surgery," he said. "Even so, in the long run, angioplasty costs less than bypass surgery for patients with one or two blocked vessels, but costs about the same as bypass surgery in patients with three blocked vessels. Both methods were comparable in terms of overall rates of death and subsequent heart attacks."

In the Jan. 9 New England Journal of Medicine, Hlatky and his co-authors concluded: "Balloon angioplasty has a significant cost advantage over bypass surgery in two- vessel coronary disease [$52,930 vs. $58,498], but the costs are similar in three-vessel disease [$59,430 for surgery vs. $60,918 for angioplasty]."

On average, the 465 patients in the angioplasty group returned to work five weeks sooner than did the 469 patients in the surgery group, who stayed off the job for 11 weeks. "But interestingly, once back, both groups had about equal lost time from work because of health complications," Hlatky said.

The average initial cost of angioplasty was 65 percent that of surgery ($21,113 vs. 32,347), but after five years the total health care cost of angioplasty was 95 percent that of surgery ($56,225 vs. $58,889) for individual patients, the researchers found.

During the first three years of follow-up, scores on a test measuring the ability to perform common activities of daily living (the Duke Activity Status Index) improved more in patients assigned to surgery than in those who received angioplasty. "Generally, patients who received cardiac surgery were free of angina. But other measures of quality of life improved equally in both groups throughout the follow-up period, and results varied so widely among individuals that from a consumer standpoint the results of the two procedures are close enough in medical terms that the patient's preferences are the most important in the choice between them," Hlatky said.

Angioplasty patients required more primary care visits during the five-year study, but overall, surgery patients required more office visits because of their greater need to see their surgeons in the weeks and months after the operation. Angioplasty patients required more prescription medications than surgery patients in the years following the procedure, the study disclosed.

While mortality rates during the four years were similar for most patients undergoing one of the two procedures, diabetic patients who received surgery tended to live longer, with lower treatment costs than did diabetic patients who had angioplasty. Generally, young patients with fewer complications or other ailments did better overall with procedure than did their older counterparts in the study.

"What we are talking about are two significantly different methods of correcting heart disease: a major surgical procedure that involves breaking chest bones, [compared] with a much simpler procedure that, under local anesthetic, involves inflating a balloon to reduce or eliminate blockage by widening the area of blood flow," Hlatky said.

The difference between the two methods, he said, is roughly comparable to the difference between unclogging a sink by pouring a chemical down the drain vs. opening and replacing worn and clogged pipe joints leading to the sink.

"There are obvious advantages and disadvantages to both methods," said Hlatky. One factor would be whether the patient wants to get the highest assurance that the problem will be fixed permanently vs. a method that is clearly easier, more convenient and cheaper, he noted.

"In the case of blood vessel repair, you might ask yourself if you'd rather take a longer period out of work at a time you select [as would be the case with surgery] or take a shorter period off with a somewhat higher probability that you might need the procedure repeated," he said.

Hlatky stressed that the findings were drawn from clinical studies conducted at seven major research institutions "where the options for both angioplasty and bypass surgery were equally outstanding."

"The quality of either method was not an issue," he said, "but it is obviously important for patients faced with a choice of angioplasty vs. surgery to make sure they are choosing between teams with equally excellent skills."

Clinical centers involved in the study were the University of Alabama Medical Center, Birmingham; the University of Michigan School of Medicine, Ann Arbor; the Mayo Clinic, Rochester, Minn.; the Boston University School of Medicine; the Cleveland Clinic Foundation; St. Louis University School of Medicine; and Duke University School of Medicine, Durham, N.C.

Statistical analysis was performed at Stanford by Hlatky and his colleagues, as well as at the University of Pittsburgh Graduate School of Public Health. Study authors from Stanford, in addition to Hlatky, were Iain Johnstone, professor of statistics, and Derek B. Boothroyd, a statistics graduate student.

Funding for the project, part of the Bypass Angioplasty Revascularization Investigation (BARI), came from the Robert Wood Johnson Foundation, Princeton, N.J., and the National Heart, Lung and Blood Institute, Bethesda, Md.

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