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Drug Therapy as Good as Invasive Procedures After Heart Attacks

Medications offer an equal chance of long-term survival for older folks, study finds

TUESDAY, March 15, 2005 (HealthDay News) -- Most older people who have heart attacks survive just as well with drug therapy as they do with invasive procedures like bypass surgery or angioplasty, a new study finds.

The research, which appears in the March 16 issue of the Journal of the American Medical Association, carries potentially important economic implications as well as medical ones, the study authors say.

The study, which tracked more than 158,000 elderly Medicare participants hospitalized for heart attacks in 1994 and 1995, found virtually no difference in survival over an average seven-year follow-up between those given intensive treatment with drugs like beta-blockers and those who had cardiac catheterizations and other high-tech invasive procedures.

"We found that cardiologists often are not doing the things that work," said Therese A. Stukel, who led the study while at Dartmouth Medical School and now is vice president for research at the Institute for Clinical Evaluative Sciences in Toronto. "We are doing things that are more invasive and more costly."

There are indications that high-tech treatment is being done simply because it is available, Stukel said. The rate at which it is used "is completely related to the supply available in a given area," she said.

There is "a small, selective group of patients" who benefit from invasive treatments, Stukel added. But there are no guidelines that enable cardiologists to single out those patients, she said.

The American College of Cardiology is trying to develop such guidelines, said Dr. Harlan M. Krumholz, professor of medicine at Yale University School of Medicine, and co-author of a commentary in the same issue of the journal. "The ACC is devoting considerable effort to try to improve decision-making and be sure people get the treatment they need," he said.

There are ongoing studies designed to determine which patients benefit most from specific treatments, such as drug therapy or invasive procedures, Krumholz said. He headed one such study that found the most effective strategy was to take someone who had just suffered a heart attack to the nearest hospital, rather than encountering the delay needed to go to a center with specialized high-tech facilities.

Krumholz said that both his study and the Stukel study are important to the current effort to organize care for people with heart attacks and other cardiovascular conditions that require immediate treatment.

"There is a movement afoot to regionalize cardiovascular care in the same way as with trauma centers," he said. "That is an interesting idea, but there are a lot of reasons to go slow, a lot of variables we don't know about."

The case for centralized trauma centers is easy to make, Krumholz said, because the need for such a center is clear when someone suffers a major injury.

But it's not so simple for heart attacks because "the symptoms are not always obvious, with crushing chest pain," he said. "The greater majority of patients have more subtle symptoms, often those that mimic indigestion. What do you do with those people? Send them to a major center even if they don't have heart disease?"

Any decision about treatment of such patients will have "a deep impact on medical costs," Stukel said. "Invasive procedures are far more costly than drug treatment, and don't appear to have more benefits for most patients."

The lure of high-tech treatment is hard to resist, Stukel said, but "there can be a misguided translation of what works in an ideal situation to the treatment of most patients."

"We're struggling to determine appropriateness, who really benefits from this kind of treatment," Krumholz said. "When you look around the country, you see big variations in the extent of its use. We need to find a way to see who needs this stuff."

More information

The American Heart Association offers guidelines on the telltale signs of a heart attack.

SOURCES: Therese A. Stukel, Ph.D, vice president for research, Institute for Clinical Evaluative Sciences, Toronto, Canada; Harlan M. Krumholz, M.D., professor of medicine and epidemiology and public health, Yale University School of Medicine, New Haven, Conn.; March 16, 2005, Journal of the American Medical Association
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