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The Globe and Mail

Angioplasty or bypass surgery?<br/> It really depends on the hospital.

Dr. Eric A. Cohen, Deputy Head of the Schulich Heart Program, Sunnybrook Health Sciences Centre

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TORONTO, Ontario – Patients who get chest pain due to severe narrowing of the arteries in the heart have two choices: the first is angioplasty (a procedure where a balloon is inserted and inflated to widen a narrowed or obstructed blood vessel in the heart) and the other is the more traditional coronary bypass surgery (open heart surgery where a healthy blood vessel from another part of the body is grafted onto the heart to circumvent a blocked artery). In patients with two or three blocked arteries, the choice between these procedures varies significantly across Ontario.

According to a new study led by researchers at the Institute for Clinical Evaluative Sciences (ICES) and Cardiac Care Network of Ontario (CCN), there is greater than three-fold variation across hospitals in Ontario.

"This significant variation highlights that treatment preferences and practice styles of the cardiologists at different hospitals greatly impacts whether a patient is treated with angioplasty or bypass surgery," says lead author Dr. Jack Tu, ICES Senior Scientist and Senior Scientist in the Schulich Heart Research Program at Sunnybrook Research Institute.

"While many patients may still prefer angioplasty because it is less invasive, we recommend that patients receive more information about their treatment choices after a coronary angiogram and that surgeons be consulted more often when surgery is potentially one of the treatment options available," adds Tu.

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The Variations in Revascularization Practices in Ontario (VRPO) study of 8,972 patients undergoing a coronary angiogram in Ontario between April, 2006 and March, 2007 found:

• A greater than three-fold variation in the ratio of angioplasty to bypass surgery procedures performed in Ontario's hospitals that perform cardiac procedures.

• The lowest ratios were in Windsor and London Health Sciences heart centres.

• The highest ratios were in the Sault, Sudbury and Ottawa heart centres.

• The cardiologist performing the diagnostic angiogram in patients appeared to be a key decision maker as to the type of treatment (medications, angioplasty or bypass surgery) the patient ultimately received.

• Many two and three-vessel patients were treated with angioplasty immediately after an angiogram without involvement of a cardiac surgeon in the decision making process.

"While the conclusions of the study are based on a subset of patients and not applicable to all angioplasty vs. bypass surgery decisions, the findings remind us of the need to engage discussion on treatment options, particularly for patients with complex coronary artery blockages for whom either procedure may be an option," says Kori Kingsbury, CEO at the Cardiac Care Network of Ontario.

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According to Dr. Eric A. Cohen, Deputy Head of the Schulich Heart Program, Sunnybrook Health Sciences Centre, and co-lead of the project, "there is considerable variation between hospitals in the use of angioplasty and bypass surgery. We found that much of the decision making between the two procedures is – quite appropriately - based on clinical factors like the location and severity of blocked heart arteries or whether the patient just had a heart attack. However, we found that the treating hospital and the type of specialist involved also influenced the pattern of care. This led us to believe that there could be more consistency and transparency in these sorts of decisions."

The study, Determinants of Variations in Coronary Revascularization Practices, appears in the December 12, 2011 issue of the Canadian Medical Association Journal (CMAJ), and was funded by was funded by an operating grant from the Ontario Ministry of Health and Long-Term Care.

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