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News & World Report’s list of "America’s Best Hospitals" (see article, p. 103) had significantly lower risk-adjusted 30-day mortality rates than other hospitals, regardless of whether the other hospitals were similarly equipped:
Top-ranked hospitals 15.6%
Similarly equipped hospitals 18.3%
Non-similarly equipped hospitals 18.6%
Use of aspirin (in ideal candidates)
Top-ranked hospitals 96.2%
Non-similarly equipped hospitals 83.4%
Use of beta-blocker (in ideal candidates)
Top-ranked hospitals 75%
Similarly equipped hospitals 61.8%
Non-similarly equipped hospitals 58.7%
Cholesterol carriers are better predictors
Researchers have identified three proteins whose blood levels are major indicators of repeat heart attack risk.1 The cholesterol carriers may provide a better analysis for determining risk than the usual cholesterol level test because they are more sensitive detectors. Measurement of the proteins is a strong indicator even when compared to other risk factors such as smoking, high blood pressure, diabetes, and cholesterol level itself.
"This finding provides a foundation for better risk identification and a more rational approach to care of a patient and prescription of drugs that target the primary risk factor for heart attacks," wrote Arthur J. Moss, MD, professor of medicine and cardiology at the University of Rochester (NY) Medical Center and lead author of the study. Because the proteins are more sensitive risk detectors than cholesterol level, they may identify more individuals at risk and one day may replace cholesterol testing.
In the study, Moss and colleagues measured blood levels of apolipoprotein (apo) A-1, apo B, and D-dimer as well as 11 other blood factors in 1,045 patients who had experienced recurrent heart attacks. Apo A-1 is a cholesterol-removing scavenger, Apo B adds cholesterol to the blood, and D-dimer is associated with the creation of blood clots.
If low apo A-1, cholesterol accumulates
When apo B levels are high, the protein deposits cholesterol on the inside surface of the plaque. Then the cholesterol moves into the plaque, increasing the size of the fatty deposit. At normal levels, apo A-1 picks up the deposits before they enter the plaque, but if apo A-1 levels are low, cholesterol accumulates and forms more plaque, stressing the coating that usually keeps the plaque in place. If sufficiently weakened, the coating ruptures and forms a blood clot, triggering a heart attack and stroke.
In the study, 81 participants had a second heart attack; 25 died. Only the three proteins were associated with an increased risk of heart attack. Individuals with low apo A-1, high apo B, and high D-dimer blood levels were eight times more likely to experience a heart attack within two years than those with more normal levels, the study found. Patients with an abnormal blood level of only one of the proteins were twice as likely to have another heart attack within two years.
The study results support continued use of cholesterol-lowering diet, exercise, and drugs in at-risk patients, wrote Moss, because the therapy favorably alters the concentration of proteins and helps reduce risk of plaque rupture as well as reducing clotting tendency. Yet other experts claim that at least 20 million Americans at risk of heart attack are not prescribed statins — one in five patients receive the drugs which cost $75 to $100 per month.
James Froehlich, MD, of the University of Michigan in Ann Arbor reviewed surveys of 250,000 patient visits over a six-year period and reported his findings at a cardiology conference in New Orleans this past spring. He found that 14% of those diagnosed with cardiovascular disease got a prescription for a statin. In addition, only half of heart attack patients leave a hospital with a prescription.
1. Moss AJ, Goldstein RE, Marder VJ, et al. Thrombogenic factors and recurrent coronary events. Circulation 1999; 99:2,517-2,522.