Post-Heart Attack Drug Therapy Improving

But many doctors aren't keeping up with the latest medications, study finds

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By Amanda Gardner
HealthDay Reporter

MONDAY, Nov. 14, 2005 (HealthDay News) -- While there has been much improvement in how physicians prescribe medications after heart attacks, many still fall short, a new study finds.

In particular, doctors need to pay more attention to newer heart drugs to ensure compliance with American College of Cardiology/American Heart Association guidelines.

"Two-thirds of patients missed one or more indicated therapy," said Dr. Rajendra Mehta, lead author of the study and a faculty researcher at Duke Medical Center and Duke Clinical Research Institute in Durham, N.C. "Only one-third received all the indicated therapies."

"More than 40,000 lives across the U.S. can be saved if guidelines are followed," Mehta added.

But another expert said the overall picture is a good one.

"It's encouraging that some things are looking better," said Dr. Carl Lavie, medical co-director of cardiac rehabilitation and preventive cardiology and director of the exercise laboratories at the Ocshner Clinic Foundation in New Orleans/Baton Rouge.

Lavie was not involved with the Duke research, which was presented Monday at the American Heart Association's Scientific Sessions 2005 in Dallas.

The purpose of the study was to see if nationwide quality-improvement initiatives regarding non-ST elevated heart attacks were having an effect.

Non-ST elevated heart attacks are one of two major types of heart attack. The other is ST-elevated, the researchers said.

ST refers to a portion of the graph produced by an electrocardiogram. ST-elevated heart attacks require more immediate medical attention.

"The main issue with non-ST-elevated myocardial infarctions [heart attacks] is that more people are involved in the care," Mehta explained. "Emergency departments have to make decisions based on risk stratification, [and] the internal medicine doctor is involved. Cardiologists come in the back door."

The American College of Cardiology (ACC) and American Heart Association (AHA) updated their guidelines for non-ST elevated myocardial infarctions in 2002, using information from recent, large-scale clinical trials.

The guidelines focus on administering anti-platelet medications, heparin (to prevent blood clotting), glycoprotein IIb/IIIa inhibitors (also to inhibit clots) or beta blockers within the first 24 hours of admission to the hospital. After discharge, the guidelines recommend prescribing aspirin, beta blockers, ACE inhibitors or statins and addressing cardiac rehabilitation. Health staff should also encourage smoking patients to quit smoking, and patients with poor eating habits to change their diets for the better.

In its study, Mehta's team analyzed treatments given to nearly 114,000 patients at 434 U.S. hospitals, part of a national quality improvement initiative known as CRUSADE. CRUSADE is funded by Schering-Plough, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership and Millennium Pharmaceuticals.

"We wanted to see if participation [in CRUSADE] helped hospitals improve," Mehta explained.

Overall, adherence to recommended prescribing practices increased from 71 percent in 2002 to 81.5 percent by the end of 2004, the study found.

Aspirin was prescribed to more than 96 percent of heart patients while newer drugs such as Plavix (clopidogrel) or glycoprotein IIb/IIIa inhibitors were prescribed less than 75 percent of the time.

Ideally, newer drugs should also be prescribed 95 percent of the time or more, the researchers said.

Use of beta-blockers rose in hospitals from 76 percent to 88 percent during the same time period. On an outpatient basis, usage improved from 81 percent to 89 percent.

Plavix treatments went from 36 percent to 54 percent in hospitals and from 50 percent to 72 percent after discharge.

Glycoprotein IIb/IIIa inhibitors, newer on the scene, improved from 33 percent to 47 percent, the researchers found.

In-patient aspirin prescriptions rose from 92 percent to 97 percent and outpatient from 93 to 96 percent.

Meanwhile, dietary modification rose from 66 percent to 83 percent, smoking cessation from 59 percent to 85 percent, and cardiac rehabilitation from 37 percent to 65 percent.

These researchers had earlier reported that adherence to the guidelines corresponded to an improvement in outcomes, with mortality risks increasing by 3.1 percent at hospitals whose adherence went down and declining by 37 percent at hospitals whose care improved.

The way the data was collected may mask some of the nuances of treatment, outside experts pointed out.

"I agree that you'd like for some numbers to be 90 to 99 percent but some of the data can be misleading," Lavie said. "Are there some reasons that doctors aren't prescribing some of these medications and did the researchers factor this in? What if the patient tells them they refuse to take a statin?"

More information

For more on heart attack and heart attack prevention, head to the National Heart, Lung, and Blood Institute.

SOURCES: Rajendra Mehta, M.D., faculty researcher, Duke Medical Center and Duke Clinical Research Institute, Durham, NC; Carl J. Lavie, M.D., medical co-director, cardiac rehabilitation and preventive cardiology and director, exercise laboratories, Ocshner Clinic Foundation, New Orleans/Baton Rouge; Nov. 14, 2005, presentation, American Heart Association's Scientific Sessions 2005, Dallas

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