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Many Americans survive a heart attack only to die soon after leaving the hospital from a second heart attack or other medical problem. But a new study sponsored by the Agency for Healthcare Research and Quality suggests that heart attack patients fare better if they are treated by a cardiologist and better still if they are treated by a cardiologist and a family physician or internist rather than by a primary care physician alone after they go home from the hospital.
The researchers found that patients cared for by cardiologists on an outpatient basis following a heart attack have a lower risk of dying within 2 years than patients seen only by primary care physicians (14.6 percent vs. 18.3 percent). Also, patients cared for by both a cardiologist and a primary care physician have an even lower risk of dying within 2 years than those treated solely by a cardiologist (11.1 percent vs. 12.1 percent). In these two comparisons, patients in each group were similar in age, sex, race, and clinical characteristics, and those in the first comparison were relatively sicker with a higher risk of dying.
According to Harvard Medical School researcher John Ayanian, M.D., who led the study, the tests and procedures that cardiologists can provide their patients—such as exercise testing, angiograms, heart bypass surgery, and cardiac rehabilitation—together with the experience that primary care physicians have in managing common chronic illnesses, may explain the success of this combination.
However, the researchers did not find that the cardiologists' patients used effective cardiac drugs to any significantly greater extent than other patients. In fact, regardless of which type of physician the heart attack survivors used for followup care, many were not prescribed drugs that have been proven effective, such as beta-blockers and cholesterol-lowering medications. On the other hand, the cardiologists' patients were more likely to undergo major diagnostic and treatment procedures such as angiograms and heart bypass surgery, which may have contributed to their better outcomes.
The study also found that the patients who were less likely to see a cardiologist for followup care were those who had major chronic illnesses such as congestive heart failure, diabetes, or lung disease, and those who were black, female, or very elderly. Patients who underwent major cardiac procedures while hospitalized, such as heart bypass surgery, were more likely to receive followup from a cardiologist after leaving the hospital.
The researchers examined 1994 and 1995 data on the medical care of more than 35,000 elderly heart attack survivors for 3 months after hospital discharge—the normal timeframe for such patients to begin seeing physicians for followup. The patients, who were insured through Medicare's fee-for-service program, lived in California, Florida, Massachusetts, New York, Ohio, Pennsylvania, and Texas.
Details are in "Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction," in the November 21, 2002 New England Journal of Medicine 347(321), pp. 1678-1686.
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