- BOSTON (Reuters) - More than a quarter of the Americans who have heart
attacks each year are subjected to expensive, risky and ultimately unnecessary
procedures to reopen their clogged arteries, researchers said Wednesday.
They said that based on the new findings, about 400,000 to 600,000 Americans
each year could easily avoid coronary angiography, the high-tech procedure
in which a tube is threaded through an artery into the heart. The procedure
costs $20,000 to $25,000 per patient. Commenting on the findings, other
experts said heart surgery was a big industry and it was unlikely that
hospitals would want to switch to cheaper, less invasive methods -- even
if they worked better. Dr. William Boden, chief of medicine at the Upstate
New York Veterans Administration Health Care Network in Syracuse, and colleagues
said many patients could also avoid angioplasty, in which the clogged arteries
are stretched open, usually with a balloon. Boden's team found that the
462 volunteers who had their heart arteries reopened with the balloon technique,
or who had bypass surgery, were two and a half times more likely to be
dead within a month after their initial heart attack compared to the 458
patients whose doctors used less invasive techniques first. The less invasive
techniques include giving patients clot dissolving drugs and using non-surgical
tests, such as an exercise stress test, to first assess the degree of damage
to the heart.
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- ``We all need to collectively step back
and reassess what we're doing here,'' Boden said in a telephone interview.
``Is it wise to subject everybody to the same treatment?'' The study, published
in the New England Journal of Medicine, looked at patients with a type
of heart attack known as non-Q-wave myocardial infarction, which represents
at least 55 percent of all heart attacks. Such attacks tend to be milder
than other types. Boden estimated that half of that 55 percent should not
need aggressive treatment. Boden's is the fourth large study of heart attack
patients to conclude that aggressive treatment does not save lives and
may, in fact, carry greater risks.
-
- Yet none of the previous findings have
radically altered the way doctors treat heart attack patients, Dr. Richard
Lange and Dr. David Hillis of the University of Texas Southwestern Medical
Center in Dallas wrote in a commentary in the journal. One reason is that
a doctor who avoids angiography and angioplasty may be accused of giving
lackluster treatment. Another, according to Lange and Hillis, is that many
doctors still believe that all heart attack patients need aggressive treatment
``despite the absence of scientific support for such an approach.''
-
- In addition, they said, there are lots
of doctors trained in the aggressive techniques, plenty of expensive equipment
to perform them, and plenty of money to be made if those techniques are
used. ``This is clearly a big industry,'' said Boden, who also predicted
that neither this study nor past research was going to steer doctors away
from the aggressive treatments. ``People tend to accept what they want
to believe in and reject what they don't,'' said Boden. ``Ultimately what
will probably happen is (insurance companies) and HMOs (health maintenance
organizations) are going to say, 'We're not going to reimburse you for
a coronary angiogram or angioplasty' unless there's better evidence that
it's needed.'' The researchers stressed that angiography is clearly helpful
in some cases. Lange and Hillis said people who develop chest pain even
after being put on drug therapy, for example, can clearly benefit from
angiography, angioplasty and bypass surgery. But treatments should be guided
by the results of medical studies, they said, rather than by doctors' preferences
or other, nonmedical incentives.
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