Drug therapy may be comparable to invasive cardiac procedures for elderly patients with heart attack

Although the type and intensity of treatment for acute myocardial infarction (AMI) [heart attack] varies widely across the country, elderly patients who receive intensive medical treatment may have comparable survival as those who undergo invasive cardiac procedures (such as angioplasty and bypass surgery), according to a study in the March 16 issue of JAMA.

According to background information, more than 280,000 Medicare enrollees are admitted to hospitals with AMI annually. "These patients face a high risk of short-term death: 18 percent die within 30 days of admission," the authors write. "Much of the effort to reduce this high mortality rate has focused on invasive diagnostic and therapeutic interventions." The authors continue, "Noninvasive, inexpensive, medical management, including aspirin, angiotensin-converting enzyme inhibitors [ACE inhibitors], and beta-blockers [medications used to treat high blood pressure], as well as thrombolysis [therapy to reduce blood clots], reduces mortality (death) following AMI."

Therese A. Stukel, Ph.D., from Dartmouth Medical School, Hanover, N.H., and colleagues analyzed data from 158,831 elderly Medicare patients hospitalized with a first episode of confirmed AMI in 1994 - 1995, followed up for 7 years. The researchers examined the intensity of invasive management (measured as whether the patients received a cardiac catheterization within 30 days), and medical management (measured by prescription of beta-blockers to appropriate patients at discharge from hospital).

The researchers found that the patients' initial AMI severity was similar across all regions. "In all regions, younger and healthier patients were more likely than older high-risk patients to receive intensive treatment and medical therapy," the researchers note. "Regions with more invasive treatment practice styles had more cardiac catheterization laboratory capacity; patients in these regions were more likely to receive interventional treatment, regardless of age, clinical indication, or risk profile. The absolute unadjusted difference in 7-year survival between regions providing the highest rates of both invasive and medical management strategies and those providing the lowest rates of both was 6.2 percent."

"Our study confirmed that clinicians were more likely to provide invasive treatments to lower-risk than higher-risk patients in this population, despite evidence demonstrating that these treatments are associated with greater absolute improvements in older, higher-risk patients," the authors write. "Second, a more intensive medical management style was associated with improved survival regardless of the level of invasive management in the region; however, in regions with high medical management intensity, there appeared to be little or no marginal improvement associated with additional invasive treatment."

In conclusion the authors write: "Debate continues regarding the value of routine use of high technology treatment for cardiac patients. While AMI survival has improved compared with 30 years ago, invasive treatment and medical management are not optimal as practiced in the United States. . We recommend first, that a comprehensive, systems-minded approach to delivering evidence-based medical management to AMI patients be a national priority."


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