Angioplasty
and Better Drug Therapy Have Doubled Survival Rate for Heart
Attack Patients
Dr.
Kim Eagle of the University of Michigan Health System
discusses how the current treatment of acute coronary
patients has saved lives.
May 2, 2007 -- Increased
use of angioplasty and stenting, as
well as beta-blockers, statins, ACE inhibitors and antiplatelet
drugs,
has significantly
reduced the rates of heart failure, stroke, heart
attack and death over the past six years in patients hospitalized
for acute coronary syndrome (ACS) and heart attack, according
to a
study
in the May 2 issue of the Journal of the American Medical Association.
As one of the authors, Dr. Kim Eagle
of the University of Michigan Health System, states, "That
is a
magnificent
change."
The GRACE Study (Global Registry
of Acute Coronary Events) analyzed data from 44,372 patients
with ACS
to determine
if changes in the way these patients are treated in the
hospital improved
clinical
outcomes.
The patients
were enrolled and followed-up between July 1999 and December
2006 at 113 hospitals in 14 countries. Keith A. A. Fox,
M.B., Ch.B., F.R.C.P., of the University of Edinburgh,
Scotland,
was the principal author of the study.
Many randomized clinical trials
in recent years have shown strong evidence for the
effectiveness of both drug and balloon/stent treatments
in patients with ST-segment
elevation (a certain pattern on an electrocardiogram)
and non–ST-segment elevation acute coronary
syndromes (NSTE ACS) -- and these results have
led to changes
in professional practice guidelines. However,
the authors of the study write in their introduction:
"...the extent and time
course of changes in clinical practice are uncertain,
and it is unknown whether such changes are associated
with improved outcome. Previous studies have documented
substantial gaps between guideline recommendations
and clinical practice. Thus, there is a clinical
priority to determine the extent to which evidence
is applied in practice, whether this is changing
over time, and whether such changes are associated
with improved outcomes."
The researchers found that the
use of pharmacological medications increased over the
study period
(beta-blockers, statins, angiotensin-converting enzyme
[ACE] inhibitors, thienopyridines (antiplatelet drugs)
with or without percutaneous coronary intervention [PCI],
glycoprotein
IIb/IIIa inhibitors,
low-molecular-weight heparin).
During the study period, reperfusion,
the opening up of blocked arteries either by mechanical
means
or
with "clot-busting" drugs, was done increasingly
with balloon angioplasty and stenting.
In 1999 about
one-third of these acute patients received angioplasty
(PCI); in 2005 that number was almost two-thirds --
double. During the same period, the use of clot-busting
drugs in patients
with ST-segment elevation myocardial infarction (STEMI)
declined by 22 percentage points -- these trends reflect
guidelines from organizations such as American Heart
Association, American College of Cardiology and the
European Society
of Cardiology which state that angioplasty is the preferred
method for opening a blocked artery during a heart attack,
if the patient can be treated within 90 minutes.
Rates of congestive
heart failure and pulmonary edema declined in both populations.
In patients with STEMI, hospital deaths decreased
by 18 percentage points and cardiogenic shock decreased by
24 percentage points. Risk-adjusted hospital deaths declined
in
NSTE ACS patients,
as did six-month death and stroke rates. Six-month follow-up
stroke and heart attack rates declined among STEMI patients.
Together, the rates of death, second heart attack or heart failure were halved
over the six-year-period.
The
authors write:
“These data, from the largest multinational
observational cohort study of patients with an ACS, demonstrate
clear evidence of a change in practice
for both pharmacologic
and interventional treatments in patients with either STEMI or NSTE
ACS.... The changes are consistent with trial evidence and
national and
international guidelines.... For the first
time, we have demonstrated
significant reductions in hospital rates of new heart failure
in
ACS patients, over time, and reductions in mortality."
On a note for further action, the authors expressed disappointment
that the proportion of heart attack patients receiving some form
of reperfusion did not change significantly from 1999. Almost a
third of patients analyzed received no reperfusion treatment, so
there is definite room for improvement.
Burt Cohen, editor of Angioplasty.Org, commented:
"The GRACE study
shows that these current treatments not only save lives,
but can prevent much of the irreversible damage to the
heart muscle that heart attacks have traditionally caused.
What is needed now is three things. One, public
education
to
urge
patients
with chest
pain not to wait, but to get to the hospital quickly and,
if possible,
to
one
that is equipped to perform angioplasty. Two, a retooling
of the hospital triage system, so that hospital centers are
prepared to get these patients diagnosed and into the cath
lab within
the recommended 90
minute door-to-balloon time. And finally, three, prescribe
the correct medications and follow-up with patients to ensure
they are complying with their therapy and lifestyle changes."
Source: Journal of the American Medical Association / Angioplasty.Org
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