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Less Aggressive Care for More Severe Heart Disease
Date:8/5/2009

Paradox found in guidelines study

WEDNESDAY, Aug. 5 (HealthDay News) -- A study assessing the treatment of people hospitalized for heart disease has produced a worrisome finding: Those who need intensive care the most are less likely to get it.

The study of 143,999 people hospitalized between 2000 and 2008 found that those with previously diagnosed atherosclerosis -- hardening of the arteries -- were less likely to undergo artery-opening surgery and get cholesterol-lowering drug therapy than those with no such diagnosis. They also had longer hospital stays and were more likely to die in the hospital.

"We knew that patients with prior disease have worse outcomes, higher mortality and stay in the hospital longer. But we would expect these patients to be getting better therapy," said Dr. Emmanouil S. Brilakis, director of cardiac catheterization laboratories at Veterans Administration North Texas Healthcare System and lead author of a report released in the Aug. 4 issue of Circulation.. "The surprise is that they get less of the therapies recommended in guidelines compared to those who have no prior diagnosis."

The researchers used data from the American Heart Association's "Get With the Guidelines -- Coronary Artery Disease" program. They did find higher compliance with some of the guidelines for those with previous atherosclerosis. For example, 92 percent were given aspirin and a beta blocker drug more than 95 percent of the time, consistent with what was prescribed for all patients.

But while 90 percent of those who had no previous diagnosis of blocked arteries were given counseling on smoking cessation, that counseling was given to 88 percent of those with one blockage, 85 percent of those with two blockages and 79 percent of those with three blockages.

Similarly, cholesterol-lowering drugs were prescribed for 89 percent of those with no previous blockages and just 77 percent of those with three blocked arteries.

Why is this happening?

"We can only make hypotheses," Brilakis said. "Maybe some of these patients are so sick that physicians decide that being aggressive with them would not be the best course of action. Or they have been told many times to do something, and maybe physicians just give up on them."

Or maybe it's a question of money, he added. The incidence of atherosclerosis is highest among people without a lot of money, he said, "and they may not have the same health insurance coverage that other people do."

One problem is that when people think of heart disease, they think only of the heart, said Dr. Adrian F. Hernandez, an assistant professor of medicine at Duke University, and a member of the research team.

"Most people just focus on coronary disease," Hernandez said. "People may not realize the risk that is involved with multiple areas of vascular [blood vessel] disease."

"We need more education in terms of the principles of care for high-risk patients," Hernandez said. "The hope is that by highlighting this issue, we will have greater adherence to the guidelines of care."

The next step is a planned study to pinpoint the reasons for differences in care, Brilakis said. That study will question both physicians and people hospitalized for heart disease about all the factors that can affect treatment decisions, he said.

"We want to get more specific," Brilakis said. "Are patients saying they don't want aggressive treatment? Do they not have enough insurance? Why are physicians reluctant to give aggressive treatment?"

More information

Details of the "Get With the Guidelines" program are described by the American Heart Association.



SOURCES: Emmanouil S. Brilakis, M.D., Ph.D, director, cardiac catheterization laboratories, Veterans Administration North Texas Healthcare System, Dallas; Adrian F. Hernandez, M.D, assistant professor, medicine, Duke University, Durham, N.C.; Aug. 4, 2009, Circulation


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