Aggressive Treatment No Better for Acute Coronary Syndrome

Finding that conservative approach works as well contradicts previous trials

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By Ed Edelson
HealthDay Reporter

WEDNESDAY, Sept. 14, 2005 (HealthDay News) -- The latest study focused on a bundle of heart problems known as acute coronary syndrome finds no particular advantage to aggressive treatment of the condition.

In essence, Dutch researchers found that a quick move to artery-opening angioplasty didn't improve patient outcomes anymore than a wait-and-see treatment strategy, with angioplasty done later if needed.

This result flies in the face of a number of previous studies, all of which have found better results with aggressive treatment, acknowledged study author Dr. Robbert J. de Winter, director of the Catheterization Laboratory of the Academic Medical Center in Amsterdam. His report appears in the Sept. 15 issue of the New England Journal of Medicine.

Just last week, for example, British cardiologists reported that taking patients to the catheterization lab quickly reduced the long-term risk of death or nonfatal heart attacks, with the benefit seen mainly in high-risk patients.

"The lack of a difference between the two treatment strategies, and the fact that the results of [the trial] differ from the previous studies has several explanations," de Winter said.

Among those, he listed a higher rate of reopened arteries in this trial than in the earlier trials, "optimized medical therapy" that included intensive use of cholesterol-lowering statin medications and "the care of experienced cardiologists during follow-up."

According to the American Heart Association, acute coronary syndrome is an umbrella term referring to symptoms associated with myocardial ischemia -- significant reductions in blood flow to heart muscle linked to heart disease.

The study included 1,200 patients treated for acute coronary syndrome, comparing the rates of death, heart attack or rehospitalization over the next 12 months among those who got aggressive treatment or a wait-and-see strategy.

The death rate was the same in the two groups, and the incidence of all the endpoints was barely different -- 22.7 percent for the aggressive treatment group, 21.2 percent for the wait-and- see group. There were more heart attacks in the aggressive treatment group --15 percent compared to 10 percent -- but they were less likely to be hospitalized in the year after treatment -- 7.4 percent compared to 10.9 percent.

"As we've shown that both treatment strategies show equivalent clinical outcome at one year, clinical practice in the Netherlands has incorporated the [trial] findings," de Winter said.

But Dr. Samin Sharma, director of interventional cardiology at Mount Sinai Medical Center in New York City, took a skeptical view of the Dutch report.

The study has one fatal flaw, Sharma said: "It did not subdivide results on the basis of the risk profile of patients."

Previous studies have shown that "if you are a high-risk patient, the aggressive strategy is very good, if you are an intermediate-risk patient it is slightly better, if you are a low-risk patient aggressive treatment was worse than medical therapy. I wish they had divided the patients according to their risk profiles."

As for the increased incidence of heart attacks in the patients who got aggressive treatment, Sharma said it is a matter of how "heart attack" is defined. The Dutch study based its finding on a lower level of heart muscle damage than previous trials have used, he said.

The study does not change Sharma's view of how acute coronary syndrome should be treated. High-risk patients should do directly to the catheterization lab, he said, and an artery-opening procedure "guarantees you that once you go home, you will do very well."

More information

Acute coronary syndrome and its treatment are described by the American Heart Association.

SOURCES: Robbert J. de Winter, M.D., Ph.D, director, Catheterization Laboratory, Academic Medical Center, Amsterdam, Netherlands; Samin Sharma, M.D., director, interventional cardiology, Mount Sinai Medical Center, New York City; Sept. 15, 2005, New England Journal of Medicine

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