Coronary stents or bypass surgery? Although commonly used to treat acute heart attacks and narrowed arteries, stents—the scaffolds used to hold blood vessels open—can promote inflammation and scar tissue growth, causing vessels to constrict again.
The technique for inserting a stent—called percutaneous coronary intervention, or PCI—however, requires a much shorter hospital stay than traditional open-heart bypass surgery, with faster recovery times, and is much less likely to trigger strokes. Though stents are less risky for patients in the first month or so after the procedure, they are more risky—with a greater chance of heart attack and death—in the years following.
These observations stem from studies of older-generation stents, says Sripal Bangalore, MD, associate professor of medicine at NYU Langone, who points out that newer stents are designed to be more compatible with living tissue and less likely to cause clots, inflammation, and tissue growth.
In a study published recently in The New England Journal of Medicine, Dr. Bangalore and colleagues compared some of the newer-generation stents to bypass surgery. They found that stents coated with the drug everolimus, an inhibitor of inflammation and tissue growth, didn’t cause greater longer-term mortality than bypass surgery. Dr. Bangalore says that the findings about comparable mortality should make it easier for “patients and their physicians to choose more wisely between stents and bypass surgery.”
The analysis should make it easier for “patients and their physicians to choose more wisely between stents and bypass surgery," says interventional cardiologist Dr. Sripal Bangalore.
The study is based on observational data from the New York State cardiac registries. It compared outcomes of patients who had bypass surgery with those who had everolimus-coated stents implanted. The stent group, as expected, fared better in the first 30 days with lower risk of death and stroke, but in contrast to earlier studies of older stents, the stent group didn’t fare worse in the longer term for death. In the long run, the numbers of deaths in the two groups were not significantly different. Patients in the stent group had about 50 percent more heart attacks during the period compared to the bypass group, but for those patients whose stents successfully opened all of their diseased arteries, there was no significant increase in heart attacks.
Although this latest study does not settle the question definitively because it is based on observational data and not on the gold standard of a double-blind clinical trial, Dr. Bangalore says “the decision between stenting and bypass surgery should be based on weighing the up-front risk of death and stroke with bypass surgery, with the long-term need for repeat procedures with stenting.”
The study was funded by Abbott Laboratories, which makes one of the two everolimus-coated stents now on the market.