Bypassing the Bypass

Heart attack victims, their families, and their doctors often turn to drastic techniques and the latest in high-tech equipment to prolong life. But male patients are less likely to have a second heart attack or die--at least in the short term--if they forgo invasive therapies, according to provocative findings in tomorrow's New England Journal of Medicine.

Researchers at 15 Veterans Affairs medical centers wanted to evaluate different kinds of treatment for a common kind of heart attack, called a non-Q-wave myocardial infarction. This condition gets its name from the lack of a wave drawn by an electrocardiogram, or EKG, a device that charts changes in the electrical activity of the heart as it beats. The researchers randomly divided 920 patients into two groups, for invasive or conservative treatments, and followed their health for an average of 23 months.

Of those in the invasive group, 96% underwent routine coronary angiography--invasive radiography that visualizes the arteries--and 44% underwent popular "revascularization" procedures such as bypass surgery, angioplasty, or both. Patients in the conservative group only resorted to such invasive tests and therapies after physicians spotted signs of potentially life-threatening complications such as ischemia, or oxygen-starved tissue. As a result, conservatively treated subjects had only half as many of the invasive angiography procedures, and only 33% underwent revascularization. Although the survival rates for patients in both groups were about the same for those who made it through the first year after leaving the hospital, the story was quite different among patients who died quickly: The invasive group suffered two to three times as many heart attacks or deaths in the month following discharge.

This and similar studies show "with remarkable clarity and consistency" the benefits of a conservative approach to therapy, write Richard Lange and L. David Hillis of the University of Texas Southwestern Medical Center at Dallas in an accompanying editorial. When treating uncomplicated cases, physicians should not be swayed by financial incentives or a desire to use all the available technology, they say.