Aggressive Therapy After Heart Attack Backed

Drugs, quick angioplasty deemed safe and effective

THURSDAY, Sept. 16, 2004 (HealthDayNews) -- Giving patients anti-clotting drugs and an angioplasty within 24 hours of a heart attack appears to be safe and effective, even though the two-pronged therapy is considered fairly aggressive.

This approach results in fewer deaths, fewer second heart attacks, fewer second procedures to open blocked arteries, and shorter hospital stays when compared with conservative treatment, a new Spanish study says.

Ideally, patients would be given an angioplasty, a procedure to unplug blocked arteries, within two hours of arriving at the hospital, but this procedure is not generally available due to limited resources. In many cases, patients are treated conservatively with medication -- also called thrombolysis -- and an angioplasty only when symptoms dictate.

"In patients with heart attacks, the strategy of performing immediate intravenous thrombolysis followed by routine repair of the infarct-related coronary artery within 24 hours is a safe strategy, which compares favorably to the conservative approach in terms of hospital stay, need of urgent revascularization and post-discharge clinical outcome," said lead researcher Dr. Francisco F. Aviles, a professor of medicine and director of the Institute of Heart Sciences at the University Hospital School of Medicine in Valladolid.

In the study, appearing in the Sept. 18 issue of The Lancet, Aviles' group randomly assigned 500 heart attack patients from Spain and Portugal to aggressive treatment with early angioplasty or conservative treatment. Conservative treatment consisted of medical therapy and angioplasty only when symptoms indicated.

After one year, among patients given an angioplasty soon after their heart attack, 9 percent died, had another heart attack, or needed another procedure to unblock arteries, compared with 21 percent of the patients who were treated conservatively, the researchers report.

"According to our results, unlike in previous studies carried out before the widespread use of stents and modern antiplatelets, currently the strategy of performing stenting within 24 hours of thrombolysis represents an excellent alternative for the still high proportion of patients with heart attack for whom primary stent-angioplasty is not available," Aviles said.

While primary angioplasty, when patients undergo angioplasty within two hours of being admitted to the hospital, is the preferred strategy for heart attacks, it is available to less than 20 percent of patients with heart attacks, he added.

This trial combined the best of both strategies: early thrombolysis, a widely available and easily applicable treatment, followed by a routine intervention aimed at assuring both blood flow and prevention of new blockages, Aviles said.

"According to our results, this combination is safe, prevents recurrence of ischemic events, and is applicable to the entire population with heart attack regardless of geographical and logistics barriers," Aviles said, adding the treatment could start in the emergency room or even in an ambulance.

"In addition, cardiac catheterization and appropriate intervention after successful thrombolysis is highly recommended because it is safe, dramatically reduces hospital length of stay, and prevents ischemic events, as compared to the conservative approach," Aviles said.

"These are not surprising findings," said Dr. David L. Brown, director of the Cardiac Catheterization Lab and Interventional Cardiology at Beth Israel Medical Center in New York City. "The practice of treatment of these patients has evolved faster than the science, and now it's nice to see the science is actually catching up."

Brown said most cardiologists have been using early angioplasty for a long time without any data. "This paper basically verifies that this is a safe approach," he said.

"This is a small study, so it doesn't suggest that this approach is significantly better in terms of important endpoints like death or heart attack, but it does reduce the risk that patients will need additional procedures," Brown noted.

Brown added this approach has been driven partly by cost. "The length of stay is significantly shorter in the patients treated more aggressively, which saves money for the hospital," he said.

"From the patient's standpoint, this is a much more streamlined approach," Brown said. Patients who are insightful enough to know that the fact they have had a heart attack means that they have a certain amount of blockage in the coronary arteries are disappointed if an early invasive approach is not done, he added.

More information

The American Heart Association explains heart attacks.

SOURCES: Francisco F. Aviles, M.D., Ph.D., professor, medicine, and director, Institute of Heart Sciences, University Hospital School of Medicine, Valladolid, Spain; David L. Brown, M.D., professor, medicine, Albert Einstein College of Medicine, and director, Cardiac Catheterization Lab and Interventional Cardiology, Beth Israel Medical Center, New York City; Sept. 18, 2004, The Lancet
Consumer News