Cardiac bypass surgery, angioplasty and stents were no better than standard drugs for treating patients with stable heart disease -- even in the high-risk diabetes population, according to a long-awaited study.
Virtually the same proportion diabetic heart patients -- 88 percent -- were alive after five years whether doctors used a surgical or non-surgical approach to treatment, researchers reported at the American Diabetes Association.
Dr. Trevor Orchard of the University of Pittsburgh, lead author of the study, said the results mean that most diabetic heart patents can stay on non-surgical therapy unless their arteries become so blocked that there's no other option.
"There's no compelling reason for urgency," he said.
For cardiologists, the research project, known as Bypass Angioplasty Revascularization Investigation 2 Diabetes study (BARI 2D), provided more conclusive proof that there is relatively little advantage in bypass surgery or stenting in most cases, even with patients whose heart disease is complicated by diabetes.
It's the latest round in an old debate about whether to treat patients who have narrowed coronary arteries with medicine or to use surgical procedures.
The surgical procedures go by the general term "revascularization" because they deal with the blood vessels that supply the heart.
One kind, called Percutaneous Coronary Intervention (PCI), generally involves angioplasty and stenting.
A doctor threads a balloon-shaped tube from an artery in the groin to a blocked artery in the heart. The balloon is inflated, compressing the plaque blocking the artery and widening it to allow increased blood flow. The doctor may also insert a wire mesh tube called a stent, which props the artery open for a longer-lasting fix.
The advantage of PCI is that it doesn't require opening the body, although it is still a surgical procedure and considered riskier than treating heart disease with medicine alone.
In bypass surgery, surgeons take arteries or veins from another part of the body and graft them onto the heart, providing unobstructed new pathways that bypass clogged arteries. This is open heart surgery, which is commonplace today but still potentially far riskier than non-surgical treatment.
The BARI 2D findings -- that patients are no more or less likely to die no matter which approach doctors take -- match evidence from an earlier trial known by the acronym COURAGE, according to an editorial that accompanied the online publication of BARI 2D in the New England Journal of Medicine.
Given the popularity of stents and bypass surgery -- and the assumption that they were superior to non-surgical treatment -- that trial created shock waves in the cardiology world.
But COURAGE also suggested that bypass surgery might still be more beneficial for heart patients who also had diabetes.
In fact, most doctors believed that diabetes patients who also had coronary artery disease would fare best with the most aggressive treatment, said Dr. Randal J. Thomas, a Mayo Clinic cardiologist who was not involved in the study.
To test that hypothesis, Orchard's group assembled an international group of 2,368 patients with both Type-2 (adult-onset) diabetes and stable ischemic heart disease.