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ORLANDO, FL -- In the first economic analysis of its kind,
Duke University Medical Center researchers have found that
heart attack patients who suffer from a stroke shortly after
the heart attack have a 56 percent increase in their medical
bills. The higher cost is due to a combination of longer
hospital stays and stroke-related procedures (such as head CT
scans). Stroke patients also are less likely than non-stroke
heart patients to receive further cardiac procedures, the
researchers concluded.

These economic findings are important, said lead researcher
and cardiologist Dr. Chen Tung, because most new therapies for
heart attacks, whether drug- or procedure-based, carry some
risk of stroke.

"As primary angioplasty and newer clot-dissolving
medications are used to treat heart attacks, it is important
that we carefully monitor stroke rates," Tung said. "Any
significant changes in these rates will not only adversely
affect patient outcome, but will have a large impact on the
cost of care."

Tung, a cardiology fellow at the Duke Clinical Research
Institute (DCRI), prepared the results of his study for
presentation Wednesday (Nov. 12 ) at the scientific sessions of
the American Heart Association.

"Patients who have a stroke on top of a heart attack are in
double jeopardy," Tung said. "They have a high death rate -
about 35 percent of them will die during their initial
hospitalization. Of those who survive, 50 percent have
significant disability, many of whom require rehabilitative or
institutional care, driving up costs."

The Duke team gathered information from the 2,600-patient
Economics and Quality of Life substudy of the GUSTO (Global
Utilization of Strategies to Open Occluded Arteries in Acute
Coronary Syndromes) trial, which compared the benefits of the
clot-busting drugs (streptokinase and t-PA) in more than 41,000
patients around the world.

There are two main types of strokes: those caused by
bleeding in the brain, and ischemic strokes, which are caused
by blockages in blood vessels to the brain. Both cut off the
supply of oxygen to brain cells, causing them to die. In the
GUSTO trial, the incidence of the two types of strokes was
about the same, Tung said.

While thrombolytic agents are effective in treating strokes
caused by blocked blood vessels, they worsen bleeding strokes.
In the current study, half the patients with bleeding strokes
died, while only 15 percent of ischemic stroke patients
died.

The team analyzed detailed economic and resource usage data
on the 352 U.S. heart attack patients who suffered a stroke
during their initial hospitalization.

Among the findings were:

The main cost driver for the initial hospitalization was the
stroke type (bleeding $27,824 vs. ischemic $38,529).

For follow-up costs, the main cost driver was level of
disability at discharge (disabled $2,623 vs. non-disabled
$5,353).

Stroke patients were less likely to receive cardiac
catheterization, 46 percent to 72 percent.

Stroke patients were less likely to receive angioplasty, 15
percent to 30 percent.

Stroke-related procedures added $2,180 per stroke
patient.

Stroke patients remained an additional 2.2 days in intensive
care units and an additional 3.1 days in regular hospitals
rooms.

"The net effect was an increase of $12,030 in costs for the
initial hospitalization, when compared to the non-stroke
patients," Tung said.

After following patients for six months, the researchers
found that medical care costs for stroke patients were almost
five times more than non-stroke patients ($17,272 vs. $3,543),
which was nearly entirely accounted for by the need for
institutional care.

"This reflects the impact of the residual neurological
deficit many stroke patients have," Tung said. "Many of these
patients require extensive rehabilitation services or
institutional care."

For stroke patients who have residual disability, their
physicians tend to view the stroke as the more serious of the
two conditions, explaining the lower rates of invasive heart
procedures, Tung said.

"Their physicians tend to be more conservative in the
management of these patients' coronary disease for two
reasons," Tung explained. "First, because of their disability,
the patients are less likely to benefit from a procedure, and
secondly, the lifespan and/or quality of life of these patients
are limited more by the stroke rather than the heart
disease."

The study was conducted at the DCRI, which manages large
multi-center clinical trials and analyzes the resulting
data.