How should you mend a broken heart?

A traditional heart bypass, rather than angioplasty, may be a better choice even for older patients, as long as they are strong enough to withstand the more invasive procedure, according to a new study. The findings, just published in the New England Journal of Medicine, suggest that the two procedures for treating occlusive coronary artery disease may not be equal in long-term outcomes.

In the study, researchers reviewed the Medicare records of 190,000 patients with two or three clogged arteries who had undergone one of the two procedures. While death rates among the two groups were similar after one year, four years after the procedure, there was a small but significant difference: Nearly 21 percent of the angioplasty patients had died, versus about 16 percent of those who had opted for bypass surgery.

However, researchers are cautious about making any definitive claims. They acknowledge that, because the bypass operation is more stressful than the angioplasty procedure, doctors have some degree of selection bias when deciding which option to use; older patients, especially, may be diverted toward the less invasive procedure, confounding a simple outcome analysis. In general, if a patient is very frail, it s unlikely that the more invasive procedure of a bypass will be the better choice.

ACSH's Dr. Gilbert Ross is intrigued by the comparative mortality rates. It s an observational study, which means that there may be plenty of confounding factors, he says. But the difference in long-term outcomes, especially in a preliminary study like this, is worth noting. Furthermore, Dr. Ross points out, the better outcome associated with bypass surgery held up when patients in similar states of health underwent different procedures. Nevertheless, Dr. Ross agrees that the clinical characteristics of a patient should still be the determining factor particularly in instances when a patient s overall health is compromised.