Heart Attack::Where to Go?

Source: http://www.medicinenet.com

Heart Attack: Less Treatment May Be Better
By Ed Edelson
HealthDay Reporter

FRIDAY, Jan. 21 (HealthDayNews) -- Someone who has a heart attack or other life-threatening heart condition may be better off going to a general community hospital than to one with a sophisticated cardiology facility, a new, large study finds.

Because the study covers so many countries, some cardiologists are cautioning against drawing specific conclusions.

The study, which covered thousands of incidents from many countries, found the short-term death rate for patients admitted to general hospitals was no different than for those who went to hospitals equipped for catheterization, a procedure in which a very thin tube is inserted into an artery. This is done to get information that can lead to bypass surgery or other invasive treatments.

The research on more than 28,000 patients in 14 countries ranging from the United States to Europe to Australia found that the six-month death rate was 14 percent higher for those admitted to hospitals with catheterization facilities than for patients who went to a hospital without such a facility. The report is in the Jan. 21 online issue of the British Medical Journal (BMJ).

The great majority of patients in the study, 77 percent, were admitted to hospitals with cardiac catheterization facilities.

Patients in the better-equipped hospitals were 10 times more likely to have an invasive procedure such as bypass surgery, the report said; 41 percent of them had such a procedure, compared to 3.9 percent of those in the less specialized hospitals. They were also nearly twice as likely to have a bleeding complication and 33 percent more likely to have a stroke.

"International cardiological societies have developed criteria which are perhaps too liberal with regards to indications for early invasive procedures," said study author Dr. Frans Van de Werf, chairman of the department of cardiology at the University Hospital Gasthuisberg in Leuven, Belgium. "Alternatively, cardiologists may do more invasive procedures than recommended by these guidelines."

Asked whether the most important finding of the study was that someone with an acute heart problem should be taken to the nearest hospital or that invasive procedures are being overdone, Van de Werf replied, "both are equally important."

The study has important implications, not only for decisions in the first minutes when a serious heart problem occurs, but also for follow-up therapy, the journal report said.

"These findings support the current strategy of directing patients with suspected acute coronary syndrome to the nearest hospital with acute-care facilities, irrespective of the availability of a catheterization laboratory, and argue against early routine transfer of these patients to tertiary care hospitals with interventional facilities," the report said.

Asked what a patient or family member could do to influence such a decision, Van de Werf said, "I am afraid not so much can be done by the patients or accompanying people."

The findings must be approached with caution because of the sprawling nature of the study, which included 106 hospitals and a wide variety of patients, said Dr. Sidney Smith, a professor of medicine at the University of North Carolina, and a spokesman for the American Heart Association.

Because the patient population was so diverse, the study is important as a "hypothesis-generating mechanism," Smith said, but it is far from definitive.

"What is needed are randomized clinical trials in which specific groups of patients can be studied," he said. "This study provides fruit for thought, but not the basis for national strategies of care."

SOURCES: Frans Van de Werf, M.D., Ph.D, chairman, cardiology department, University Hospital Gasthuisberg, Leuven, Belgium; Sidney Smith, M.D., professor, medicine, University of North Carolina, Chapel Hill; Jan. 21, 2005, BMJ online

In Malaysia, most big cities now have medical centres which are equipped with the means of carrying out interventional procedures for heart attack patients. Present thinking is that patients with heart attacks should be rushed to these centres for immediate and after care after preliminary screening. Now here we have a report in the BMJ which is saying that less treatment rather than more maybe better. But because of the nature of the study carried out, its findings should be approached with caution and at the most the study provides food for thought. Further and better controlled studies are certainly needed to form the basis of strategies for care of heart attack patients.