Deflating A Balloon

Doctors Say Study Points to Reduced Use of Angioplasty

Local cardiologists say a recent study's findings will change how they treat many stable heart attack patients who do not seek treatment until three or more days after an attack. Doctors say they'll likely perform fewer angioplasties to unblock the arteries of such people.

The federally funded study found that angioplasty -- a procedure that involves inflating a small balloon in a blocked, or occluded, artery to break up deposits of plaque -- more than three days after a heart attack did not offer stable patients any more benefits than simple drug treatment. (Previous studies have confirmed the benefits of angioplasty for patients who are in the acute phases of a heart attack.)

The study's findings, presented last month at an American Heart Association scientific session and published in the New England Journal of Medicine on Dec. 7, offer new information for how to deal with patients who don't see a doctor until several days after a heart attack, said Lowell Satler, director of interventional cardiology at Washington Hospital Center. "Once the artery is occluded and you're late, it may not be useful to open it up," he said.

Cardiologists say that cases involving patients who are still experiencing chest pain or other symptoms several days after a heart attack and patients with heightened risk factors for future cardiac events should be handled on an individual basis.

The study "completely dispels the myth that no matter what time you open [a blocked artery], it's better to open it," said Mandeep Mehra, head of cardiology at the University of Maryland School of Medicine. "It's going to change our practice." In most cases, "72 hours after an event, you're not going to open a closed artery," he said.

Accumulation of cholesterol, fat and other substances on the walls of the coronary arteries -- which supply oxygen to the heart muscle -- can block the flow of blood and lead to chest pain and other symptoms, according to the National Institutes of Health. Most heart attacks occur due to a clot that blocks one of these arteries; clots usually form in arteries that were already narrowed.

The study "started with the question, 'Does opening up a blocked artery help someone if they are more than three days after their heart attack and they're very stable and doing well?' " said Elizabeth G. Nabel, director of the National Heart, Lung, and Blood Institute, which paid for the research. "Many of us in the cardiology community thought the answer was going to be yes. But what we learned is that people with that closed artery did just fine," as long as they promptly received recommended drug treatments.

About 1 million people in the United States have a heart attack each year, according to the NHLBI. Of the approximately 515,000 U.S. heart attack patients who die each year, about half die within an hour of the start of symptoms, usually before getting to a hospital. About one-third of heart attack patients do not receive treatment to open blocked arteries -- including angioplasty or clot-busting medications -- within the recommended 12-hour window after a heart attack, reports the NHLBI.

During an angioplasty, a thin tube with a balloon or other device on its end is threaded through a blood vessel to the site of the blockage. The balloon is then inflated to restore blood flow, and a stent is often put in place to prevent re-narrowing. About 1 million angioplasties are performed in the United States each year, according to the NHLBI.

In the newly published five-year trial, 2,166 patients -- most of whom had blockages in only one artery -- in 27 countries received either angioplasty with stenting as well as medication therapy or medication therapy alone. The medications included beta blockers, ACE inhibitors, cholesterol drugs, aspirin and clopidogrel (Plavix), which patients who received stents took to prevent blood clots.

The study investigated whether performing an angioplasty in a completely blocked artery three to 28 days after a heart attack would reduce the risk of future complications and major cardiovascular events such as heart attack, death and serious heart failure. But the rates for those events were not meaningfully different in the angioplasty-and-drugs group and the drugs-only group, which surprised cardiologists.

Researchers expected that adding angioplasty to the drug regime "would reduce the risk of events over the long term, and that didn't turn out to be the case," said Judith Hochman, lead study author and clinical chief of cardiology at the New York University School of Medicine. "It should change [clinical] practice. I think our focus should be on getting patients in earlier."

"There's always been a question about what to do when someone presents late after symptoms," said Joseph Kiernan, director of the coronary care unit at Inova Fairfax Hospital.

Often these patients are persuaded by relatives to seek treatment days after symptoms subside, or a doctor may pick up a problem based on blood tests, he said. "But now they're [feeling] fine. For that particular patient, this trial is an important added piece of information."

The implications of the study are already apparent in local cardiology settings. Two weeks ago, Mehra said, he saw a 76-year-old man three days after a heart attack. "Traditionally, we would have felt compelled" to order an angiogram (an imaging procedure used to locate blocked arteries) and a likely angioplasty, but because of the new study, "he ended up being treated with medical therapy only," Mehra said in an e-mail interview.

The study "shows the importance to the public that if someone is starting to undergo chest discomfort that they seek medical attention right away," because as time passes, the "heart muscle is scarred, and there's no point in opening up that artery," Kiernan said.

The trial also highlighted the need for doctors to pay close attention to patients' complaints. "We need to be very attuned to listening to patients when they're complaining of chest pain and rapidly try to assess" the cause of their pain, Satler said, because "it has the potential to reduce mortality." ·

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