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Heart Disease

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Whenever possible, heart attack patients at high risk of death should receive angioplasty, not thrombolytic therapy

Despite growing evidence that heart attack patients who receive coronary angioplasty fare better than those who simply receive thrombolytic (clot-busting) medication, many hospitals don't have the facilities to perform angioplasty, sophisticated surgery that opens up blocked heart vessels. Treating patients at high risk of death from heart attack with thrombolytic medication may be difficult to justify, if nearby primary angioplasty is available. However, for most patients, thrombolytic therapy is an effective alternative, concludes a study supported in part by the Agency for Healthcare Research and Quality (HS10280 and HS10064).

Early identification of high-risk patients may allow most of the benefits of angioplasty to be captured without necessitating a massive restructuring of cardiac services, according to researchers from Tufts-New England Medical Center. They examined the results of 10 randomized controlled trials of a community-based sample of 1,058 patients who received reperfusion therapy for heart attack and estimated the benefits of angioplasty across different baseline individual risks.

The researchers calculated that even if all patients achieved the same relative risk reduction regardless of their baseline risk, 68 percent of the benefit of population-wide angioplasty could be captured by treating just the highest risk quartile of patients, and 87 percent of the possible population-wide benefit could be captured by treating the higher risk half of patients. In this sample, there were no deaths in the lowest risk half of patients, and 80 percent of all deaths occurred in the highest risk quartile of patients. Assuming a constant relative risk reduction, the researchers calculated that treating only the 39 percent of patients with the highest risk would result in no more deaths than population-wide angioplasty.

See "Is primary angioplasty for some as good as primary angioplasty for all?" by David M. Kent, M.D., M.S., Christopher H. Schmid, Ph.D., Joseph Lau, M.D., and Harry P. Selker, M.D., M.S.P.H., in the December 2002 Journal of General Internal Medicine 17, pp. 887-894.

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