Wednesday, August 20, 2008

Novel strategies needed to decrease mortality risk in elderly women with heart disease
By Maggie De Pano

Many patients do not undergo cardiac revascularization even after X-ray images of their blood vessels show that they have significant coronary artery disease (CAD). Treated solely with medications, these patients are more likely to die during the first year following their initial hospitalization.

Matthew T. Roe, MD, MHS

In a study published August 2008 in the Journal of the American College of Cardiology – Cardiovascular Interventions, DCRI researchers led by Matthew T. Roe, MD, MHS described the clinical factors that funnel certain patients into a medicine-only treatment strategy and what happens to them compared to patients who undergo revascularization.

Revascularization restores blood supply to the heart by creating new, additional or augmented pathways to the cardiac muscle. It is done either by puncturing the skin and guiding a catheter through a blood vessel and implanting a stent at the treatment site (percutaneous coronary intervention) or by performing a more invasive procedure where arteries or veins from elsewhere in the patient's body are grafted to coronary arteries to bypass diseased areas (coronary artery bypass surgery).

Dr. Roe and his colleagues examined a subset of 8,225 patients from a previous trial (the SYNERGY trial) that compared the efficacy and safety of two anti-clotting drugs in heart patients. For this study, they only included patients with at least one significant blockage in a coronary artery and whose CAD was diagnosed by inserting a catheter into a chamber of the heart to generate X-ray images. Fifty-two percent of these patients received a stent, 32 percent received only medications, and 16 percent had coronary bypass surgery.

The researchers found that patients who were medically-managed tended to be elderly, female and frail. They were also more likely to have other diseased blood vessels outside the heart and brain, a history of stroke or a prior coronary bypass, as well as high cholesterol, high blood pressure and diabetes. These patients did not undergo revascularization despite significant CAD due to the presence of other serious diseases, an unfavorable coronary anatomy (as in patients whose arteries were hardened by plaque), lack of resources, socio-economic disparities or patient refusal, among other reasons.

Researchers also found that with all else being equal, the risk of death one year after being released from the hospital was 7.7 percent for patients who were medically-managed, 3.6 percent for patients who underwent a stenting procedure, and 6.2 percent for patients who had bypass surgery.

The authors concluded their study by highlighting the need for new strategies that could decrease the risk of death in patients who cannot undergo or choose not to undergo revascularization. They also encouraged researchers to conduct more prospective studies designed to examine the process patients and physicians go through when deciding what strategy to use in managing significant CAD.

Other DCRI researchers who participated in the study include Mark Chan, MD, MHS; Kenneth Mahaffey, MD; Lena J. Sun, MS; Karen Pieper, MS; and Robert Califf, MD.