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Delayed Angioplasty - Big Bucks, No Bang

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Duke Health News 919-660-1306

ORLANDO, FL – In a subset of patients suffering heart
attack, adding stents to clot-busting medical therapy after the
optimal treatment window ends isn't justified, say researchers
from Duke University Medical Center.

In a follow-up to last year's widely reported Occluded
Artery Trial (OAT), which reported that catheterization didn't
seem to prevent second heart attacks if it were used more than
3 days after the initial heart attack, a group of Duke
researchers looked more closely at 951 patients to see if there
were other benefits from the procedure.

Their findings were presented today at a late-breaking
trials session of the American Heart Association's annual
meeting in Orlando.

Each year, about one million people suffer heart attacks in
the United States, and studies suggest that for many of them,
the best treatment is speedy use of clot-busting drugs or
percutaneous coronary intervention (PCI), a catheter-based
procedure that uses stents and balloons to open up blocked
arteries. Ideally, the procedures should begin within 12 hours
of the initial attack. But in real life, that doesn't always
happen because patients delay seeking help and arrive at
emergency departments too late for timely care.

Last year, OAT researchers who had followed 2,166 heart
attack patients for up to five years told the American Heart
Association annual meeting that PCI applied 3 to 28 days after
the initial attack apparently didn't make any long-term
difference in preventing second heart attacks, death, or
development of heart failure.

All participants in OAT had experienced heart attacks, were
considered high-risk, but were stable with one completely
blocked artery. All of the patients received state-of-the-art
drug therapy, but half also got the late PCI.

Focusing on a representative subset of 951 patients in the
OAT trial, Dr. Daniel Mark, a cardiologist and director of
outcomes research at the Duke Clinical Research Institute, led
a team that measured various aspects of quality of life,
including physical functioning, emotional and social
well-being, activity level and the presence and intensity of
pain. They also calculated the medical costs the U.S. patients
incurred during that period. They were looking for was
secondary benefits that might further justify the high cost of
PCI.

Mark said that the patients who got PCI plus standard
medical therapy enjoyed slightly better physical functioning
and less pain four months into treatment, but that these
benefits did not last over time. In addition, the team
discovered that it cost $10,000 more in doctor and hospital
costs to treat the PCI patients.

"What we have here is one of those cases where less is
more," says Mark. "While it may seem that going an extra step
in opening up clogged arteries late in the game makes sense, we
know that clinically, it doesn't seem to offer the advantages
we expected. In addition, the minimal initial benefits that
patients with PCI enjoyed diminished over time. Coupling that
with the higher cost, we now know that adding PCI to standard
medical care in opening blocked arteries more than a day after
a heart attack is not good value. In an era when the high cost
of health care is the subject of intense debate, this study
offers us one way we can offer high quality care for less
money."

The study was funded by the National Heart, Lung, and Blood
Institute.

Co-authors include Wenqin Pan, Nancy Clapp-Channing, Linda
Davidson-Ray, from Duke; John Ross, from Toronto General
Hospital; Rebecca Fox, from Vancouver General Hospital; Gerard
Devlin, Waikato Hospital, New Zealand; Edwin Martin, York
Health System; Eric Cohen, Sunnybrook Health Sciences Center,
Toronto; Gervasio Lamas, Mt. Sinai Medical Center; and Judith
Hochman, New York University School of Medicine.

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