Study links survival, aggressive treatment

More than 60 percent of patients who go into cardiogenic shock die.
SCRIPPS HOWARD
More aggressive treatment of some heart-attack patients can increase their long-term survival by nearly half, a new study shows.
The research, published Wednesday in The Journal of the American Medical Association, found that doing emergency angioplasty or heart bypass surgery on these patients could save 130 lives for every 1,000 treated.
About one in 10 heart-attack patients sustains so much damage to the heart muscle that the heart can't adequately supply blood to vital organs. As this happens, such patients go into a shock-like state with plummeting blood pressure and shutdown of the organs -- cardiogenic shock.
More than 60 percent of patients who go into cardiogenic shock die, making it the leading cause of death for heart-attack patients once they reach a hospital. Frequently, heart-attack shock patients are treated only with drugs and an intra-aortic balloon pump, a device that supports circulation.
But in an international trial that compared this standard care with more aggressive emergency surgery to reopen heart arteries in 302 patients, the researchers found that only 20 percent of those who got the less aggressive care were still alive six years later, compared with 33 percent of those whose clogged arteries were bypassed or reopened with balloon angioplasty.
"Our study showed a significant survival benefit that was sustained in some patients for up to 11 years," said Dr. Judith Hochman, chief of cardiology and director of cardiovascular research at New York University School of Medicine and lead author of the study. "The benefit extends even to selected patients over the age of 75."
Hochman's team had already shown in a 1999 report that the more aggressive treatment could initially save lives in the short-term -- out to about six months. Based on those findings, the American Heart Association and the American College of Cardiology started urging aggressive treatment for all heart-attack shock patients.
Not a common cure
But a 2004 survey found that only about 60 percent of shock patients younger than 75 were getting the more aggressive treatment when they reached a top-level care hospital. And only 38 percent of such patients were transferred to a major medical center between 1998 and 2001, Hochman's group found.
"Patients can do very well and clearly benefit from this therapy, but many doctors are reluctant to treat shock patients aggressively because they are the sickest of the sick and the death rate is so high," Hochman said.
Getting shock patients to a hospital that can do angioplasty or bypass surgery is also difficult, since they must be transferred by ambulance or accompanied by a doctor. "There is a lot of legitimate fear about putting a very sick patient in an ambulance," Hochman said.
Dr. Elizabeth Nabel, director of the National Heart, Lung and Blood Institute, which sponsored the study, said the results "clearly show that treating the sickest heart-attack patients early and aggressively provides a survival benefit that is sustained years after treatment."
The study, which took place at 29 hospitals in the United States, Canada, Belgium, Australia and New Zealand on patients suffering heart attacks between 1993 and 1998, gave all the new patients standard drug treatment and the heart-pumping-assistance device, but randomly assigned half the patients to get immediate bypass or angioplasty. The remaining patients were able to undergo surgery after a two-day delay.
A year after being admitted, 47 percent of the patients who got the invasive treatments were still alive, compared to 34 percent of the medications-only group.