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."
(JAMA. 2005; 293: 1329-1337. Available post-embargo at JAMA.com)
Editor's Note: Please see the JAMA study for funding information.
<b>Commentary: Regionalization of Care for Acute Coronary Syndromes</b>
In an accompanying commentary, Saif S. Rathore, M.P.H., from Yale University School of Medicine, New Haven, Conn., and colleagues write, "there is a growing movement advocating the treatment of patients with acute coronary syndromes (ACS) at regional centers with dedicated facilities. Proponents contend that regionalized ACS care will save lives by improving access to new technologies, specialist physicians, and higher-quality care not available at other centers. … In this article, we present concerns about the rationale for regionalized ACS care and outline some potential unintended consequences."
"As the article by Stukel and colleagues in this issue of JAMA suggests, treating ACS patients with high-quality medical care, which can be accomplished by all hospitals without additional facilities, may reduce the need for interventional procedures. Also, focusing on the adoption of newer therapies ignores the fact that many inexpensive, readily available, established therapies remain underused in ACS patients."
"No study to date has provided convincing evidence that triaging patients to higher-volume hospitals will actually reduce mortality. Hospital size, technology, and specialization do not guarantee high-quality ACS care, just as the absence of these attributes does not preclude high-quality ACS care."
"… the current data are insufficient to endorse a policy requiring such a fundamental change. Clear, compelling evidence of the benefits of ACS regionalization within the United States and a better understanding of its potential consequences are needed before implementing a national policy of regionalized ACS care."
(JAMA. 2005; 293: 1383-1387. Available post-embargo at JAMA.com)
Editor's Note: Mr. Rathore is supported by a National Institutes of Health/National Institute of General Medical Sciences Medical Scientist Training grant. Co-author Dr. Volpp is supported by a VA HSR & D Research Career Development Award and a Doris Duke Charitable Foundational Clinical Scientist Development Award.
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