Efforts to standardize heart care are working

People who suffer a heart attack or severe chest pain today are much less likely to die, or to experience long-lasting effects, than their counterparts even a few years ago, according to a new international study in the May 3 issue of the Journal of the American Medical Association.

It's the first time that a study has shown a significant drop in the rate of heart failure and death over such a short time in this population.

The study finds that the change occurred at the same time that hospitals increased their use of certain drugs, tests and procedures that have been proven to help reduce the immediate and long-term impact of acute heart problems. The results suggest that concerted efforts to standardize heart care are working.

But, the authors caution, there are clouds in this sunny sky. Many patients who could benefit from all of the proven treatments aren't getting them. Previous data have shown that the U.S. actually lags behind some other countries in several aspects of acute coronary care.

The study is from the Global Registry of Acute Coronary Events (GRACE), which has collected data from 44,372 patients treated at 113 hospitals in 14 countries. The new paper is led by cardiologists from the University of Edinburgh in Scotland, Hospital Bichat in France and the University of Michigan Cardiovascular Center.

All the patients had suffered either a kind of severe heart attack called ST-elevated myocardial infarction (STEMI), or had acute coronary syndrome (ACS), which includes non-STEMI heart attack and a kind of chest pain called unstable angina.

Between 1999 and 2006, the use of heart-protecting drugs in these patients increased markedly, including use of aspirin, cholesterol-lowering statins, clot-reducing drugs called glycoprotein IIb/IIIa inhibitors, blood thinners such as clopidogrel and heparin, and blood pressure-reducing drugs including ACE inhibitors.

At the same time, the use of angiography to see blocked arteries in the heart and angioplasty as an emergency or secondary treatment to reopen blockages increased by more than 30 percent in STEMI patients and around 20 percent in ACS patients.

As the use of all these treatments increased, the death rate for patients both in the hospital and in their first six months after going home decreased significantly. So did the risk that patients would develop heart failure, have pulmonary edema, or suffer a stroke in their first six months after hospitalization.

"These findings are exciting because they provide good evidence that improved use of guideline- based treatments has resulted in fewer deaths and fewer patients with heart failure in those that present to hospital with heart attack or threatened heart attack," says Keith A. A. Fox, MB. ChB., FRCP, lead author of the paper, co-chair of GRACE and a professor of cardiology at Edinburgh.

"These data are extremely encouraging, and suggest that we're definitely improving heart care and patients' outcomes through the uniform use of evidence-based, proven treatments and the development of guidelines to help providers understand the evidence behind them," says Kim Eagle, M.D., FACC, a co-author on the paper and co-chair of the publication committee for GRACE. He is the Albion Walter Hewlett Professor of Cardiovascular Medicine at the U-M Medical School and a director of the U-M Cardiovascular Center.

"Yet, these data and other studies show that we still have a ways to go before every heart attack and ACS patient receives the full range of tests and treatments that we know can benefit them," Eagle continues. He notes, for example, that only 85 percent of STEMI patients and 83 percent of ACS patients in the study received a statin in 2006, when virtually all such patients should receive the cholesterol-lowering drug. And only 53 percent of STEMI patients received emergency angioplasty, when it has repeatedly been shown to be life-saving in such patients.

"The U.S. especially has a lot of ground to gain, compared with European and Canadian hospitals, in reducing the time lag between hospital presentation and acute coronary artery angioplasty," Eagle adds. "That's why efforts to improve hospitals' systems for providing this kind of care are so important."

U-M heart specialists lead or co-lead several key efforts to increase the use of evidence-based STEMI and ACS care in the state of Michigan. Eagle, for instance, has co-led the Guidelines Applied in Practice , Myocardial Infarction project sponsored by the American College of Cardiology, which has improved heart attack care at dozens of Michigan hospitals and provided a model for hospitals nationwide. He recently received the Raymond Bahr award from the American Society for Chest Pain Centers in recognition of his leadership role in such projects.

At the same time, U-M CVC director of interventional cardiology Mauro Moscucci, M.D., has co-led the Blue Cross Blue Shield of Michigan Cardiovascular Consortium, which has focused on improving angioplasty care and has saved both lives and dollars. U-M heart failure specialist Todd Koelling, M.D., is leading a Michigan-wide effort to improve heart failure care. And U-M is heavily involved in the national D2B Alliance, which seeks to accelerate the use of emergency angioplasty by helping hospitals be ready to deliver the life-saving treatment as quickly as possible after a patient arrives.

So, as hospitals work to improve their heart care even more, the new study's authors hope that additional gains in patients' outcomes can be made. They are continuing to collect data on hospitalized STEMI and ACS patients in 30 countries around the world, and to contact patients at home after their initial hospitalization to get follow-up information. GRACE now includes 236 hospitals in North America, South America, Europe, Asia, Australia and New Zealand.

Meanwhile, Eagle says, patients should ask their doctors and nurses questions about what drugs they should be receiving both in the hospital and after they go home. Aspirin, statins, beta blockers and ACE inhibitors should be on the medicine cabinet shelves of nearly every patient who has ever been hospitalized for chest pain or a heart attack , and patients need to make sure to keep taking those drugs long after they leave the hospital, perhaps for life.

At the same time, while the study did not include data on patients' diet, exercise and tobacco habits, those lifestyle components are crucial to preventing further problems. Says Eagle, "We all have a role to play in making sure that the news in heart attack care continues to be good."