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Bypass surgery may offer survival advantage over angioplasty in older heart patients

Heart disease patients with clogged coronary arteries often face two options to clear blockages if their heart medications don’t control their symptoms: bypass surgery, which involves making a large incision in the chest to reach the heart, or minimally invasive angioplasty, where a catheter wire is threaded into the artery via a tiny incision.

While the recuperation from angioplasty is far easier than from bypass, a study published Tuesday in the New England Journal of Medicine suggests that bypass might offer a survival advantage.

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The study compared nearly 190,000 heart disease patients with stable coronary disease over age 65 who chose to undergo either bypass surgery or angioplasty (usually along with a stent placement) and found no survival difference at one year after treatment; four years following treatment, however, about 16 percent of the bypass patients had died compared with nearly 21 percent of the angioplasty patients.

Yet, the study didn’t look at how that compared with mortality rates in patients who stuck with traditional management of stable heart disease: medication therapy.

Previous research has shown that while angioplasty and bypass can be lifesaving if administered within hours after a heart attack, neither extends the lives of those with stable heart disease any better than medications. Nor do they prevent future heart attacks better than drugs such as baby aspirin or statins.

Both, though, appear to offer short-term relief from symptoms such as chest pain, fatigue, and shortness of breath in patients whose symptoms aren’t well managed by medications -- which is why some heart patients opt to have the interventions.

Often, patients prefer angioplasty because they can be back to themselves in a day or two, compared with being in pain and less mobile for four to six weeks after a bypass. On the other hand, bypass patients often get more effective and sustained relief from symptoms, according to study co-author Dr. Jeffrey Popma, director of interventional cardiology at the Beth Israel Deaconess Medical Center.

“Patients with diabetes, those who have blockages difficult to treat with conventional angioplasty, those with a reduction in heart muscle function, and those with complex disease,” he added, “may well have a bigger survival benefit from bypass beyond what we found in our study.”

Popma, who’s trained to perform angioplasties, said he frequently teams up with surgeons to discuss the best treatment choice for particular patients but ultimately leaves the decision up to the patient. “Sometimes, the surgeon and I firmly agree on the best method, and the patient doesn’t want to do what we recommend,” Popma said. “We almost always end up deferring to the patient’s wishes and values.”

Related: Angioplasty vs. drug treatments

Deborah Kotz can be reached at dkotz@globe.com. Follow her on Twitter @debkotz2.
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