In a study colliding with established practice, recovery from small heart attacks went just as well when doctors gave drugs time to work as when they favored quick vessel-clearing procedures.
The surprising Dutch finding raises perplexing questions over how to handle the estimated 1.5 million Americans who each year have small heart attacks — the most common kind. Most previous studies support the aggressive approach.
“I think both strategies are more or less equivalent. I think it is more a matter of patient preference, doctor preference, logistics and, in the long run, it could be a matter of cost,” said the Dutch study’s lead researcher, Dr. Robbert J. de Winter, at the University of Amsterdam. The wait-and-see approach is usually cheaper.
Under current American and European guidelines, patients with small heart attacks must be rushed into a hospital laboratory to test for coronary-artery blockages. Then, they are usually given bypass operations or angioplasties, which clear the clog with a little balloon. In the Dutch study, drugs were given time to work in half the patients before any decision on further treatment.
It is not extraordinary for respected studies, with varied patients and methods, to reach opposing conclusions. This question, though, is particularly important, since it bears on the care of so many patients.
Less aggressive approach
The latest findings were laid out Thursday in the New England Journal of Medicine. The Dutch team focused on 1,200 heart-attack patients for a year. Though they were undergoing heart attacks, their heart-wave tests did not indicate major attacks. These smaller heart attacks can still cause suffering and death.
The second group got the drugs, but no aggressive measures until much later and only if symptoms persisted. After a year, just over half needed the more aggressive treatment.
Few died in either group — only 2.5 percent. In the first group, 23 percent either died, suffered another heart attack, or went back to the hospital with chest pain. Only 21 percent did in the conservative group — a statistical tie.
Dr. Eugene Braunwald, the Harvard cardiologist who chaired the professional committee devising the U.S. guidelines in 2002, said this study alone — though well executed — should not change current practice. “I don’t think one study should upset the whole apple cart,” he said.
Others said it’s time to consider at least modest changes in guidelines and practice.
“We’ve lived in this sort of mortal fear that we’re going to be shortchanging the patient who doesn’t go right to the lab, and I think this study shows that the group that didn’t go right to the lab didn’t do badly at all,” said Dr. William Boden, a cardiologist at Hartford Hospital, in Connecticut. He wrote an accompanying editorial.
The researchers hypothesize that recent improvements in drug therapy have evened the odds between the two styles of treatment. They also say that small heart attacks that often occur with angioplasties — usually viewed as benign in the past — may help explain the findings.
Dr. Alice Jacobs, a Boston University cardiologist who speaks for the American Heart Association, cautions that the aggressive approach might prove better over a longer period than one year. She said the guidelines should stand for now.
