Many heart attack patients fare better with noninvasive treatment regimens
Many heart attack patients fare better with noninvasive treatment regimens
Physician habit, money override mounting medical evidence
People who suffer mild heart attacks do better with conservative treatment than with high-tech procedures such as heart catheterization or bypass surgery, according to a recent study.1 The 30-day post-heart-attack death rate was 4.8% among aggressively treated mild heart attack sufferers, compared to 1% among the other group.
If all this sounds familiar, you're right - it's nothing new. The study is the latest in a series of investigations with similar outcomes. Yet, given a battery of evidence for medical, noninvasive strategies, use of aggressive strategies persist for mild heart attacks. "And this study isn't going to get people polarized in a different direction," says lead investigator, William E. Boden, MD, chief of Medical Service at Upstate New York VA (Veterans Affairs) Healthcare at Syracuse.
"People have long argued that aggressive management is the most expeditious, but this study shows differently," he says. Even at one year, the death rates were 10% vs. 6%, respectively. (See "Primary Endpoint Events (Death or MI) at Various Time Points," p. 131.) Hospital stays were 9.5 days for the early invasive group compared to 8.2 days for the conservative group. (See related story, "Study advocates medical management of mild MIs," p. 133.)
Why less is better for mild heart attacks might lie in the physiological events, explains Boden. "Perhaps these patients had unstable plaque formations so instrumentation of the coronary artery right after a heart attack aggravates the condition." Often mortality rates are lower if surgery is delayed for three weeks. So why does the practice continue contrary to the evidence?
A case of blurred margins
Here's the history as Boden sees it: In the early 1980s, several studies showed that patients with non-Q-wave infarctions (mild heart attacks) were at risk for recurrent episodes. "The high-risk subset patients in those trials were at risk. But many cardiologists have blurred the margins. They've lost sight of the variances of risk, and it's currently popular to see all patients as high risk," he states.
Fueling the trend were 1987 recommendations by the American Heart Association and the American College of Cardiologists that non-Q-wave infarction patients should have heart catheterization in the absence of any scientific basis. In 1991, they modified their recommendations, "but it did not change the way cardiology is practiced," Boden adds.
Among cardiologists, the issue of medical vs. invasive strategies is a hot political topic. Henry Anderson, MD, chief quality officer, at Swedish American Health System in Rockford, IL, describes one school of thought:
"We have a group of cardiologists here who believe that [heart] muscle saving is the gold standard. Angioplasty is the only way to learn how much artery narrowing there is and how much muscle damage will follow the reduced oxygenation," Anderson says.
That logic follows preventive principles, he continues. "Muscle saving makes sense because if they save the muscle now and there's a recurrence, the patient will be in better shape to withstand the damage."
Boden counters that one of his findings would surprise muscle saving proponents: Only 1% of the mild heart attack patients either had subsequent episodes or died. (See graph, "Kaplan-Meier Analysis," p. 131.) "Most cardiologists would have expected 10 to 15 times that," he observes. Perhaps it's those hunches that drive the medical decisions affecting the lives of the 800,000 people who have mild heart attacks each year.
Others, such as Stephen Wallach, MD, a cardiologist in Kailua, HI, uses the amount of ischemia as his gold standard. (Ischemia is localized anemia due to lowered blood supply from narrowed arteries.) Wallach says, "Most people should be risk stratified based on the degree of continuing symptoms or ongoing ischemia. If the results of a treadmill are [within the safe range], then I might treat medically."
"But some people are explosive time bombs and they need to be fixed ASAP," he adds. "It depends on the amount of ischemia. In some instances, the most conservative approach is the most aggressive approach."
Boden says that when he presents his findings at medical conferences, 80% of the feedback from peers is surprisingly agreeable. "I'll often have a doctor come up to me and say 'Thanks, this vindicates the way I've practiced for years.'"
Enter money
Economics is a factor here, he argues. "There's a hard core of 10% to 20% of cardiologists who do not want to see studies like this published because the interventional approach to cardiology is a huge industry. There's an oversupply of cath labs, and werunning amuck doing procedures that are not necessary."
"These therapies do get expensive," adds Anderson. Yet, speaking for the aggressive treatment strategists, he says, "Angioplasty is less expensive than bypass surgery. And there's the debate. To pick and choose on the basis of economics is unacceptable. We don't want people to merely survive. We want them to survive with a good quality of life."
Who's pulling whose strings?
"A lot of this is doctor-driven," Wallach says. "Deep down, most patients don't want to be invaded. They snipe and snarl when their doctors suggest invasive procedures."
Anderson does not dispute the profound influence of doctors. "Under the pressure of a heart attack, very few doctors sit down with patients and their families and explain the options and evaluate what the quality of life would be with each," he concedes. 's easy to tilt the patient one way or another because the patient sees the doctor as the expert."
Still, let's not put all the heat on the doctors, Boden cautions. "Societal expectations play a big role. In the U.S., we think everything that can be brought to bear should be brought to bear. This is heightened by television shows that embellish the high tech aspects of medicine."
In the face of all that, he says, it takes courage for a physician to practice conservative medicine. Yet, ironically, rising consumer savvy and the fortitude to challenge doctors' decisions could also spur medical prudence, Boden says. But everyone will listen eventually "when the insurance companies say, 'You can revascularize all you want to, and we're not going to pay for it unless you can show us you have delayed and used conservative strategies first,'" he adds. That day may not come soon, though.
Evidence and insurance decisions
A few studies like this one don't sway payers' reimbursement guidelines, says Eric L. Book, MD, group vice president and chief medical officer at Wellmark Inc., Blue Cross/Blue Shield of Iowa and South Dakota in Des Moines, IA. Instead, it's clinical guidelines formulated by an objective entity like the Agency for Health Care Policy and Research in Silver Spring, MD, that influence reimbursement changes, he says. "Even then, we would want to leave some room for individual treatment decisions."
In reality, a significant period of time elapses between the accumulation of clinical evidence and actual changes in reimbursement practices, says Ellen Gaucher, MPH, MSN, Wellmark's vice president for quality and customer satisfaction. That aside, she continues, "payment rates have led to more changes than anything else, it's sad to say." Meanwhile, small improvements based on evidence like Boden's study will continue to percolate, one facility at a time, she says.
Gaucher notes, "Groups like IHI [Institute for Healthcare Improvement in Boston] are responsible for a lot of the facility-level change."
As for individual practitioners, Boden says, "It would be naive to think this or any study will change cardiology practices - and that's a sad indictment. As doctors, we revere the randomized, controlled study, and this is the seventh one that shows such results. We say, 'show us the evidence,' but we don't really practice evidence-based medicine in this country."
In the short term, Boden says quality improvement managers can make a difference by raising the question of how their institutions treat mild heart attack patients. "Studies like this should be brought to the attention of the administrators and the doctors," he says. "We need to risk stratify our patients into high, moderate, and low risk for recurrent heart attacks. I don't regard intervention as bad. But as doctors, we need to look inward and ask ourselves, 'Do I need to aggressively treat all my patients?'"
Reference
1. Boden WE, O'Rourke RA, Crawford MH, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. N Engl J Med 1998; 338:1,785-1,792.
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