Despite changes in standard treatment practice guidelines issued by the American College of Cardiology, American Heart Association and the European Society of Cardiology several years ago, there has been no meaningful change in the nation's practice of opening completely blocked coronary arteries with balloons and stents in the days after a heart attack, according to a new study published in the July 11, 2011, issue of Archives of Internal Medicine. The new study concludes that cardiologists in the United States are still performing this procedure late after a heart attack.
"Our new finding is disappointing; a lot of painstakingly gathered clinical trial evidence is being disregarded a few years after its publication and guideline changes," says Judith S. Hochman, MD, the Harold Snyder Family Professor of Cardiology at NYU Langone Medical Center and senior author of the study.
In the new study, Dr. Hochman and her colleagues examined a registry of angioplasty and stent procedures performed in nearly 29,000 patients at nearly 900 hospitals in the United States. The monthly rate of late procedures showed no sign of declining during the period from 2005 to 2008.
"There continues to be reimbursement for the late procedure, and many patients expect their physicians to open their arteries, regardless of the delay, so these physicians may be concerned about malpractice suits if they don't comply," says Dr. Hochman. "However, the existence of national clinical guidelines should protect physicians from that liability."
Dr. Hochman was the lead author of the landmark Occluded Artery Trial (OAT), published in 2006 in the New England Journal of Medicine. It concluded that opening a totally blocked heart attack-related coronary artery more than 24 hours after a heart attack does not reduce patients' chances of death, a second heart attack, or heart failure, compared to more conservative treatment with medication alone and selective use of the opening procedure in a small subset of these patients. "We found evidence in substudies that both groups improved their heart function (ejection fraction) substantially and to the same degree," says Dr. Hochman.
The OAT study finding led to new treatment guidelines in 2007. Dr. Hochman and her colleagues, however, have learned that cardiologists are still doing the procedure in patients 24 hours or more after a heart attack. "It's intuitive that having an open artery is better than having a closed artery, and many people don't want to let go of that belief," she says.
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