New drugs, angioplasty boost decline in heart patient deaths

Study shows `remarkable improvements' in care over past 7 years

May 02, 2007|By Thomas H. Maugh II | Thomas H. Maugh II,LOS ANGELS TIMES

Increased use of angioplasty and the introduction of new drugs over the past seven years have nearly halved the number of hospitalized heart attack victims who die or suffer severe heart failure, an international team of researchers reports today.

The report showed "remarkable improvements" in the care of heart attack patients in all 14 countries studied, said Dr. Gregg C. Fonarow of the University of California, Los Angeles' Geffen School of Medicine, who was not involved in the study.

"It is not simple to manage these patients. Many therapies need to be applied very rapidly," Fonarow said. This study shows that individual drugs and treatments that have been validated in clinical trials can be combined in the real world to produce "very meaningful benefits."

"Our study supports the fact that hospitals are using new treatments effectively," said Dr. Keith A.A. Fox of the University of Edinburgh in Scotland, who led the study published in The Journal of the American Medical Association.

For every 1,000 patients admitted to hospitals, he said, there are 39 fewer deaths and 90 fewer patients with new heart failures compared with only seven years ago. In the United States, with as many as 5 million patients suffering the conditions each year, that would translate to nearly 200,000 fewer deaths if all hospitals were following the treatment guidelines.

"There have been a lot of lives saved, a lot of complications averted," said Dr. Joel M. Gore of the University of Massachusetts Medical School, another of the study's leaders.

The group could not attribute the improvements in outcomes to any one treatment or medication, concluding that it was the total of all combined that was responsible.

The improvements including a doubling in the use of balloon angioplasty to clear blocked arteries and the increased use of a variety of old and new drugs, including aspirin; cholesterol-lowering statins; anti-clotting drugs called glycoprotein IIb/IIIa inhibitors; blood thinners such as clopidogrel and low-molecular-weight heparin; and blood pressure-reducing drugs such as ACE inhibitors.

"The individual medications are all very good, but we were concerned that when it actually came to treating patients, the thought of using five or six right from the start would be intimidating," Gore said. "We're very encouraged to see that people are using all of the evidence-based medicine and showing excellent results."

There was also, he said, "a marked reduction in the use of ineffective medications," including clot-dissolving enzymes, calcium channel blockers and unfractionated heparin.

The study, called the Global Registry of Acute Coronary Events, or GRACE, enrolled 44,372 patients at 113 hospitals from July 1999 to December 2006. All the patients had either suffered a severe heart attack in which the coronary arteries were totally blocked or suffered from acute coronary syndrome, which includes other types of heart attacks and a kind of chest pain called unstable angina.

Death rates from severe heart attacks while in the hospital were reduced from 8.4 percent at the beginning of the study to 4.5 percent at the end, according to the report. The risk of progressing to heart failure declined from 20 percent to 11 percent.

"That's a huge drop for this complication of heart attacks," Gore said.

The rate of progression to a critical form of heart failure called cardiogenic shock declined from 7.1 percent to 4.7 percent - a crucial drop because 70 percent of such patients die.

Among patients who suffered a severe heart attack, the risk of a subsequent stroke fell from 1.3 percent to 0.5 percent, while the risk of a second heart attack went from 4.8 percent to 2 percent. Similar declines were observed for patients who suffered milder heart attacks.

Despite these gains, there is still room for improvement, said another co-author of the study, Dr. Kim A. Eagle of the University of Michigan Medical School. He pointed out that only about 85 percent of patients received statins, for example, while all of them should. He also noted that only 53 percent of severe heart attack patients received emergency angioplasty, even though it has repeatedly been shown to be lifesaving.

Current guidelines call for a heart attack victim to receive angioplasty within 90 minutes of hospital admission.

"This puts everybody on notice that the standard of care is to minimize the time from when a patient has chest pain until a blocked artery is opened up," said Dr. Mason Weiss of Centinela Freeman Regional Medical Center in Inglewood, Calif.

The study was funded by the pharmaceutical company Sanofi-Aventis through an unrestricted educational grant to the University of Massachusetts to maintain the GRACE registry. Most of the authors have received funds from pharmaceutical companies.

Thomas H. Maugh II writes for the Los Angeles Times.

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