Older Heart Patients Do Well With Drugs
Surgery to Treat Heart Attacks Often Unneeded, Study Shows
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The survival difference was much smaller when patients treated with optimal combinations of drugs were compared with those who were treated surgically.
The study is not the first by the Dartmouth research group to question the superiority of some of the most aggressive medical treatments.
"Our message is that more health care does not necessarily equal better health care," Stukel says. "Drug therapy is inexpensive and noninvasive, and there is a lot of evidence showing that it works. There are clear guidelines identifying patients who benefit from early invasive therapy, but they aren't being followed."
Cardiologist Richard Stein, MD, agrees that too many heart patients are getting cardiac catheterization and other invasive treatments they don't need. Although these procedures generate big money for hospitals, the American Heart Association spokesman says he does not believe economics is driving treatment.
"I think the cardiologists who do them believe these invasive treatments benefit the majority of patients," he says. "But this belief system is not supported by the clinical evidence."
Yale professor of medicine Harlan M. Krumholz, MD, says doctors need to do a better job of explaining the risks and benefits of various treatments to patients and including them in the decision-making process.
"A lot of patients are under the impression that angioplasty or bypass surgery will keep them from having another heart attack," he says. "This is not necessarily true for many patients."
In an editorial accompanying the study, Krumholz and colleagues warn that a movement to treat all heart patients at facilities that specialize in cardiac care is not supported by the clinical evidence.
"Hospital size, technology, and specialization do not guarantee high-quality (heart) care, just as the absence of these attributes does not preclude high-quality care," they write.
The benefits of drug treatment after a heart attack are undisputed. But only about 60% of patients end up taking the drugs they need in the correct dosages.
For the vast majority of patients this regimen includes low-dose aspirin, a statin to lower cholesterol, and drugs that lower blood pressure.
Stein says far too few patients achieve target LDL cholesterol levels of below 100 and blood pressure of 135/85 even though these targets are generally reachable with aggressive drug treatment.
"Most patients these days are put on aspirin, but we don't lower cholesterol and blood pressure enough and we don't use enough beta-blockers," he says. "We just aren't doing a good enough job of prescribing the drugs at the dosages that have been shown to help patients the most."