Wednesday, September 14, 2005

Heart Attack Patients Do As Well With Drugs As With Invasive Steps

Heart-Attack Patients Do as Well With Drugs As With Invasive Steps
By SYLVIA PAGÁN WESTPHAL Staff Reporter of THE WALL STREET JOURNALSeptember 15, 2005; Page D1

For patients who are having a mild heart attack, medication and monitoring may work as well as the standard, more-invasive approach now used by hospitals, a new study says.
The study, published in today's New England Journal of Medicine, adds fuel to an already heated debate over how to treat the more than one million patients admitted into U.S. hospitals each year complaining of chest pain, and whose electrocardiogram shows they are likely suffering a form of mild heart attack. These attacks stem from a narrowing, rather than a complete blockage, of an artery feeding the heart. About two-thirds of patients complaining of heart-attack symptoms or chest pain fall into this category, says the American Heart Association.
The standard approach for these patients is to take a blood test to see if an enzyme known as troponin T is elevated, which doctors consider to be an indicator of high risk that the patient is having a heart attack. Current U.S. and European guidelines recommend an invasive procedure immediately, which involves threading catheters through the patient's arteries to help get an image of the vessels near the heart.
If narrowed vessels are found, doctors usually open up the artery with a balloon and place a stent -- a metal mesh tube -- in the artery to keep it open. If the blockage is very serious doctors may turn to bypass surgery.
Until a few years ago this wasn't the standard approach. A more-conservative tactic was also commonly done, giving patients a cocktail of drugs in hopes their cardiac symptoms would go away, says Robbert J. de Winter, a cardiologist at the Academic Medical Center in Amsterdam, who wrote the New England Journal study. If the symptoms didn't subside, more-invasive imaging often followed, along with balloon treatment, stenting or bypass surgery.
But in recent years, a number of large clinical trials came out favoring the catheter-based invasive strategy from the outset, showing this approach yielded lower rates of chest pain and fewer heart-attack recurrences. Guidelines from the American College of Cardiology and the American Heart Association, as well as European authorities, were amended to recommend the invasive strategy.
But newer anticlotting, cholesterol-lowering and other state-of-the-art drugs have become more widely used since the earlier studies. Moreover, the previous studies mixed lower-risk with higher-risk patients. So Dr. de Winter and his collaborators ran a new study using a cocktail of these medicines in combination with careful monitoring, against the more-aggressive approach in high-risk patients.
The researchers were still expecting to find the invasive therapy to be better, but to their surprise, their study of 1,200 men and women ages 29 to 83 found that the conservative approach appeared at least as effective as the invasive approach.
A year after the initial hospital visit, an equal percentage of patients, 2.5%, had died in each group, researchers found. In that time, subsequent heart attacks occurred in 15% of patients undergoing the catheterization, versus 10% of those on the conservative strategy. Visits to the hospital for symptoms were slightly more frequent -- 10.9% versus 7.4% -- among patients assigned to the conservative approach.
By being more conservative, Dr. de Winter's team spared dozens of patients surgery or stenting. One year after the initial visit, 54% of patients in the conservative-treatment group had received stents or undergone bypass surgery, compared with 79% of patients in the invasive group.
The study was conducted at 42 hospitals in the Netherlands, and was supported in part by grants from several pharmaceutical and medical-device companies. Some of the investigators in the trial reported receiving grants and consulting fees from the pharmaceutical companies making some of the drugs given to the patients.
William E. Boden, a cardiologist at the University of Connecticut, who wrote an accompanying editorial in the journal and wasn't involved in the study, believes the likely explanation for the new results was better drugs. "I think that leveled the playing field," he says.
He thinks the results should serve as a wake-up call to physicians. The main point of the study, he says, is not to discourage doctors from intervening with an invasive procedure, but to make them realize they might not have to do it right away. The study shows "you are not putting the patient in harm's way by deferring intervention for a few days," Dr. Boden says.
This message may be especially important to smaller hospitals that don't have the in-house capability to implant stents or do bypass surgery, Dr. de Winter adds. Currently those hospitals transfer their high-risk patients to a larger center within 48 hours. But Dr. de Winter says doctors at these facilities might now feel reassured to keep some of those patients longer.
Cardiologist Gregg W. Stone, of the Columbia University Medical Center, cautioned that most clinical trials still suggest early intervention is better. Dr. Stone, who has conducted research for stent maker Boston Scientific, says, "The totality of the evidence certainly suggests that the aggressive approach ... is appropriate."

Write to Sylvia Pagán Westphal at sylvia.westphal@wsj.com

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