Study Examines Comparison Of Heart Treatments

Congress has been clamoring for more head-to-head comparisons of medical treatments, so doctors and patients can know when one treatment is more cost-effective than another. But a new study of common heart treatments published in this week's New England Journal of Medicine shows that even head-to-head comparisons don't provide easy answers.

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Congress has been clamoring for more head-to-head comparisons of medical treatments so it's easier to tell when one treatments better than another. In fact, $1.1 billion of the federal stimulus package will fund exactly this kind of research. But a new study of life-saving heart treatment shows that even direct comparisons don't always provide easy answers. It was published in this week's New England Journal of Medicine. Here's NPR's Patti Neighmond.

PATTI NEIGHMOND: It sounds simple enough. Take a group of patients who aren't in the middle of a heart attack but do have severely blocked arteries. Divide them into two groups. Give one traditional treatment - heart bypass surgery. Give the other a cheaper, a less invasive option - angioplasty to unclog the arteries, followed by the insertion of a little tube, or stent, to keep the arteries open. Researchers in this study divided up 1,800 patients at heart centers across Europe and the U.S., then they tracked how well each treatment worked, and whether there were serious problems in the following year. Cardiologist David Hillis chairs the Department of Medicine at the University of Texas Medical School.

NEIGHMOND: During that 12 months, did the patients die? Did they have a myocardial infarction, a heart attack? Did they have a stroke? Or did they have to return, during that 12 months, for another procedure - another stenting procedure or another bypass operation?

NEIGHMOND: Patients who had the stenting procedure were more likely to have one of those problems. That sounds like a thumbs up for bypass. But when scientists looked more closely, they found the problem most patients had was this: An artery clogged up again, and the stenting had to be redone. When they looked at stroke, heart attack and death, there was no difference between the two treatments.

NEIGHMOND: And the chance of one of those happening during that one year of follow-up was, in fact, identical in the two treatment groups. It was about 7 and a half percent in the bypass surgery group, and 7 and a half percent in the stent group.

NEIGHMOND: So, now the two treatments seem roughly equal. But here is the catch: One is extremely invasive surgery - bypass means cracking open the chest, hospitalization for about 10 days, and months of recovery. Stenting may have to be done over again, although the risk is small - about 10 to 15 percent in the first year - but it's far less invasive. Patients are in the hospital for a few days and back on their feet, says Dr. Hillis, within a week. In a related editorial, Hillis says patients need to thoroughly discuss options and priorities with their doctor. Some may feel like one of his patients who traveled extensively on business.

NEIGHMOND: I told him, well, if you have the stenting, you know, you may be in Zurich or Paris or Rome, and all of a sudden, you will have a recurrence of chest pain. You'll have to get on a plane, fly home. We'll repeat the angiogram and do another procedure. And he said, boy, that sounds awfully unattractive. What can I do to absolutely minimize the chance that I'll have to do that? And my answer was, have bypass surgery. And he said, let's do it.

NEIGHMOND: Now, some people will need another bypass down the road,but usually, it lasts at least 10 years. Hillis's patient is happy with his decision. But others may prefer stenting. And sometimes, individual anatomy dictates which procedure to have. Cardiologist Elizabeth Nabel heads the National Heart, Lung and Blood Institute.

NEIGHMOND: Medicine is never completely straightforward, never completely black and white. We need to use the evidence as we have it today.

NEIGHMOND: In the past, patients with severe heart disease had only one option: major surgery. The good news from this study is that for many patients, an alternative is just as life saving.

Patti Neighmond, NPR News.

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