Bypass surgery may relieve chest pain better than angioplasty plus stent

American Heart Association
Tuesday, 16 September 2003

Bypass surgery is better than stent-assisted angioplasty at relieving chest pain and improving quality of life in the year after the procedure, researchers report in today's rapid access issue of Circulation: Journal of the American Heart Association.

The study is the first randomized trial to compare improvement in cardiac-related health status using a disease-specific questionnaire to evaluate the burden of angina (chest pain) in patients undergoing stent-assisted angioplasty versus coronary artery bypass surgery (CABG).

CABG uses blood vessels from the chest or leg to reroute blood flow around arterial blockages and improve blood and oxygen supply to the heart. In angioplasty, a balloon-tipped catheter is inserted into an artery narrowed by plaque deposits. The balloon is then inflated, compressing the plaque and reopening the vessel. Wire mesh tubes called stents are placed in the vessels to keep them open.

"While patients who underwent either intervention showed tremendous improvement in their health status at one year, they had less chest pain if they had coronary artery bypass surgery than if they had stenting," said the study's senior author, William S. Weintraub, M.D., professor of medicine at Emory University School of Medicine in Atlanta.

The analysis is based on data from the Stent or Surgery trial in which 988 patients with more than one blocked heart artery were randomly assigned to receive either CABG or percutaneous coronary intervention (PCI, also known as angioplasty). Five hundred had CABG; 488 had PCI. The patients' average age was 61. Seventy-nine percent were male, 14 percent had diabetes, 24 percent had acute coronary syndrome and 45 percent had hypertension.

Patients' cardiac-related health status was measured at baseline, after six months and after one year using the 19-item, self-administered Seattle Angina Questionnaire. The questionnaire focused on physical limitations, angina stability and frequency, treatment satisfaction and perception of quality of life. Overall, treatment satisfaction was high for both groups.

On a scale of 0 to 100, scores for physical limitations, angina frequency and quality of life improved significantly in both groups, from 14.3 points to 38.2 points at one year. But compared to those assigned to PCI, bypass patients showed greater improvement, by an average of two to three points.

"The advantage of CABG was unanticipated," Weintraub said. "CABG is initially much more expensive, but the cost advantage of PCI may be lost if the procedure must be done several times." About one in five patients who undergo angioplasty experience a re-narrowing of their arteries (known as restenosis) that necessitates a repeat intervention within a year, he said.

"Since there were substantial improvements in chest pain and quality of life in both groups, the findings should be used more as a guide to treating patients with angina rather than viewed as an endorsement of one procedure over another," he said. "If patients want to know which one will make them feel better, the answer is coronary artery bypass surgery."

Co-authors are Zefeng Zhang, M.D., Ph.D.; Elizabeth M. Mahoney, Sc.D.; Rodney H. Stables, M.D.; Jean Booth, B.Sc., M.Sc.; Fiona Nugara, B.Sc.; and John A. Spertus, M.D., M.P.H.

For more information, or to contact American Heart Association, see their website at: www.americanheart.org