Study: Chances missed to avoid many heart attacks

Some patients don’t receive aggressive treatment

Despite the fact that clogged arteries in the legs usually mean clogged arteries near the heart, a new study led by a University of Michigan cardiologist finds that doctors often fail to give heart-protecting care to people who have clogged blood vessels in their legs. Lack of aggressive treatment for body-wide problems means missed heart attack prevention opportunities, the study shows.

In a presentation at the American Heart Association’s annual Scientific Sessions, November 13-16, 2005, the University of Michigan Cardiovascular Center, Ann Arbor, researchers showed data on 553 patients who came to five Michigan hospitals for procedures to re-open clogged blood vessels in their legs and abdomens. Such blockages are called peripheral artery disease, or PAD. The study shows that among such patients, those who also had a history of heart problems were more likely to receive drugs to lower their cholesterol and blood pressure, compared with those who hadn’t had heart problems.

"Patients who have severe PAD but haven’t experienced heart-related problems are under-treated when it comes to medical therapy, especially statin drugs to lower cholesterol," says senior author P. Michael Grossman, MD, an assistant professor of cardiovascular medicine.

The patients in the study were all having procedures called peripheral vascular interventions, or PVIs, which are nearly identical to angioplasty and stenting procedures performed in blocked or narrowed heart arteries.

Once diagnosed, the first treatment for PAD patients is to exercise, lose weight, and stop smoking. The same actions that are known to help their hearts. But medicines such as blood thinners, cholesterol drugs, ACE inhibitors and BETA blockers, and procedures such as PVI, are used when lifestyle changes don’t do enough.

Before their PVI procedure, 91% of the heart patients were taking blood-thinning drugs such as aspirin or clopidogrel to prevent the formation of dangerous clots, compared with 83% of patients with no heart history. An even larger gap in statin use was seen: 65%, compared with 51% of non-heart patients. And BETA blockers, which lower blood pressure and heart rate, were used in 62% of heart patients, compared with only 42% of non-heart patients.

A systems’ solution

While there may be any number of reasons why individual physicians fail to follow national guidelines for treating PAD, Grossman proposes a "systems solution" for addressing the problem.

"You have to decide this is an important QI initiative and build a system where health care extenders who are really tuned to this kind of thing can help screen patients’ meds and make sure they are on the right ones," Grossman recommends. "We’ve seen this kind of phenomenon with cardiovascular problems, where QI initiatives have made a difference in improving outcomes with guideline recommended therapies. Armed with this data, the next step is to look at ways to improve."

There is a window of opportunity to make an impact on the disease process at the time of diagnosis, says Grossman, when the patient and family are focused on the disease. "That’s when you can hit them and get success with smoking cessation, taking meds, exercise, and so forth," he suggests. "It’s a real opportunity for those of us who do these procedures to make an impact not only on the disease, but on patients’ long-term outcomes, by putting them on the right meds."

In addition, he says, the hospital must do a better job of focusing on the problem and communicating with primary care providers about screening for PAD and, when it’s found, to treat the patient aggressively with medications known to improve their long-term health. (For more on the treatment of PAD, go to www.med.umich.edu/cvc/; in the "search" box, type in "PAD.")

Getting docs on board

There are additional strategies that can be employed to ensure greater physician compliance with national guidelines, says Grossman.

"There are a couple of things that seemed to work well in GAP [The Acute Myocardial Infarction GAP Project in Michigan; www.acc.org/gao/mi/ami_gap.htm]," he says. "First, have standard order sets computerized or on paper, so, for example, when the patient is admitted, in the written orders there is perhaps the name of a BETA blocker, and the physician just fills in the dose. In the discharge summary, you include a list of meds the patient is on, and a field on the screen says something like, These medications have been shown to improve long-term outcomes in patients like you.’" This way, he notes, if the patient is not on one or more of these medications, they may be prompted to ask their physician why they aren’t on them.

Such strategies also help focus attention on who is filling out the discharge papers, Grossman adds. "For example, there are opportunities here to have an impact on the patient’s diet. So you might want to set up a system where the dietitian can see the discharge papers," he suggests. "Or, you can have smoking cessation team meetings with the patient."

This critical time is what Grossman refers to as a therapeutic window.’ "You can catch a few patients and really make a difference, because family members can really influence behavior," he asserts.

As for follow-up, this is generally handled by the primary care provider, but, says Grossman, "In my practice, I like to see patients back in a month to see if they are doing okay, and then do some long-term follow-up to see if there is evidence of re-narrowing of the arteries. If there is a non-internal medicine trained physician taking care of them, it may be important to work closely with them."

For more information, contact:

P. Michael Grossman, MD, assistant professor of cardiovascular medicine, University of Michigan Hospital Health Center, Ann Arbor, MI. Phone: (734) 936-5608.