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Clarification to This Article
The article incorrectly said that a generic formulation of the heart attack drug Plavix is available. In August 2006, Apotex, a Canadian pharmaceutical company, briefly sold a generic version of the drug, also known as clopidogrel. Plavix's maker, a joint venture of Sanofi Aventis and Bristol-Myers Squibb, got a court injunction prohibiting further importation. In some parts of the United States, however, generic clopidogrel continued to be available for as long as a year. The supply is now exhausted. Generic versions of the drug, unapproved by the Food and Drug Administration, can be bought over the Internet. Those drugs can be seized or refused entry by the government.
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As Health-Care Quality Rises, So Does Price

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The revolution in heart attack care has occurred over the working careers of cardiologists who aren't even very old.

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"When I was in medical school, about all we had to offer was oxygen, morphine and prayers," said Eric Topol, director of the Scripps Translational Science Institute in La Jolla, Calif.

Topol, who turned 55 last month, graduated from medical school in 1979. For 15 years he was head of cardiology at the Cleveland Clinic, where he helped run some of the clinical trials that have changed treatment so dramatically.

Today, someone having a heart attack who gets to a hospital in time is likely to get cardiac catheterization, angioplasty, the placement of a medicated stent, therapy with four anticoagulant drugs and, on discharge, a handful of lifetime prescriptions.

"There's been a complete transformation in how it's handled just since I've been in medicine," Topol said.

That transformation has saved the lives of millions of Americans.

In 1970, the death rate from coronary heart disease was 448 per 100,000 people. In 1980, it was 345. In 1990, it was 250. In 2000, it was 187. In 2006, it was 135 -- less than a third of what it was during Topol's senior year of high school.

About half the decline since 1980 is a consequence of better medical care, and about half is the result of a more favorable "risk profile" for Americans -- less smoking, lower cholesterol, better blood pressure.

To understand the step-wise change in complexity, outcome and cost of treatment, it's useful to understand what a heart attack is and how it threatens life.

"Myocardium" means "muscle of the heart," and "infarction" is from the Latin verb meaning "to plug up." A myocardial infarction occurs when an artery delivering oxygen-rich blood to the beating heart muscle is suddenly narrowed or blocked, usually by a blood clot forming on a cholesterol-encrusted blood vessel wall.

If the situation persists, the muscle tissue suffocates and dies. The result is a permanently and sometimes fatally weakened heart and a susceptibility to abnormal rhythms. The goal of treatment is to unplug the artery and stop any arrhythmia. The second task proved easier to address than the first.

The first coronary care unit was opened in the United States in 1962. It let physicians continuously monitor the heart rhythms of heart attack patients and shock them out of the most dangerous one, called ventricular fibrillation. Researchers estimate that between 1968 and 1976, the spread of such units across the country accounted for a 14 percent decline in mortality from heart attacks.


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