Older Heart Patients Benefit From Aggressive Treatment

Angioplasty And Stenting Prevent Deaths

Quick use of artery-opening procedures such as angioplasty and stenting in emergency situations could halve the number of deaths or second heart attacks in older people, according to a report in the Annals of Internal Medicine.

The new study found no significant differences in results for younger patients, those ages 65 and under, who had conservative treatment (watchful waiting and drug therapy) compared to those who got more aggressive therapy - angioplasty, stent, or surgery.

But it was a very different story for patients ages 75 and older, says study author Dr. Richard G. Bach, an associate professor of medicine at the Washington University School of Medicine in St. Louis.

"For death or recurrent myocardial infarction, there was over a 50 percent reduction," Dr. Bach says.

The study included more than 2,200 patients treated in 169 hospitals in nine countries. Only 10.8 percent of the patients over 75 who had aggressive treatment died or had a second heart attack, compared to 21.6 percent of those who received conservative treatment, Dr. Bach notes.

"A 10 percent absolute percentage reduction is very remarkable," he says. "For every 1,000 patients, 100 events were prevented."

Care Taken To Treat Older Patients Cautiously

Traditionally, physicians have hesitated to use aggressive treatment with older heart patients because they feared it would lead to major bleeding that could cause serious damage.

In the new study, the incidence of major bleeding was higher among patients who got aggressive treatment - 16.6 percent, compared to 6.5 percent for those who got watchful waiting. But, the problems caused by that bleeding were outweighed by the benefits of the aggressive artery-opening strategy.

The findings have important implications for the older people who make up a large proportion of the more than 1.4 million patients who get emergency treatment for heart attacks and other severe cardiac problems each year in the US, Dr. Bach says.

This study included a larger number of older people than previous ones, he adds.

Discovery Lends New Support for Intervention

The findings may heighten awareness among clinicians about the advantages of aggressive treatment, Dr. Bach says, and "they are something that may be reflected in future guidelines."

The results cannot be applied to all older patients who require emergency heart treatment, Dr. Bach notes. The study excluded patients who had other major illnesses, such as cancer.

The finding "adds a significant amount of credibility to the idea that older people can be treated aggressively with an interventional approach," says Dr. H. Vernon Anderson, a professor of medicine at the University of Texas Health Science Center in Houston, who also was involved with the study.

There has been "hesitation in much of the medical community toward a more aggressive approach to older people" because of the risk of excess bleeding and other complications, Dr. Anderson says.

"The data from this study indicate that even with those problems, older people do better with an aggressive approach," he says.

Always consult your physician for more information.

Online Resources

American Heart Association

Centers for Disease Control and Prevention (CDC)

HealthierUS.Gov

National Heart, Lung, and Blood Institute (NHLBI)

National Institutes of Health (NIH)

National Library of Medicine

US Health and Human Services

September 2004

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Angioplasty Basics

Percutaneous transluminal coronary angioplasty (PTCA) is performed to open blocked coronary arteries caused by coronary artery disease (CAD) and to restore arterial blood flow to the heart tissue without open-heart surgery.

A special catheter (long hollow tube) is inserted into the coronary artery to be treated. This catheter has a tiny balloon at its tip. The balloon is inflated once the catheter has been placed into the narrowed area of the coronary artery.

The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow.

The use of fluoroscopy (a special type of x-ray, similar to an x-ray “movie”) assists the physician in the location of blockages in the coronary arteries as the contrast dye moves through the arteries. A small sample of heart tissue (called a biopsy) may be obtained during the procedure to be examined later under the microscope for abnormalities.

The physician may determine that another type of procedure is necessary.

This may include the use of atherectomy (removal of plaque) at the site of the narrowing of the artery. In atherectomy, there may be tiny blades on a balloon or a rotating tip at the end of the catheter. When the catheter reaches the narrowed spot in the artery, the plaque is broken up or cut away to open the artery.

Atherectomy is used when the plaque is calcified, hardened, or if the vessel is completely closed. Another type of atherectomy procedure uses a laser, which opens the artery by "vaporizing" the plaque.

Stent Basics

In the past few years, many refinements have been developed in the PTCA procedure. One common procedure used in PTCA is stent placement.

A stent is a tiny, expandable metal coil that is inserted into the newly-opened area of the artery to help keep the artery from narrowing or closing again.

Once the stent has been placed, tissue will begin to form over it within a few days after the procedure. The stent will be completely covered by tissue within a month or so.

It is necessary to take a medication, such as aspirin or clopidogrel (Plavix™), which decreases the “stickiness” of platelets (a type of blood cells that clump together to form clots to stop bleeding), in order to prevent blood clots from forming inside the stent.

Newer stents (drug-eluting stents, or DES) are coated with medication to prevent the formation of scar tissue inside the stent. These drug-eluting stents release medication within the blood vessel itself.

This medication inhibits the overgrowth of tissue that can occur within the stent. The effect of this medication is to deter the narrowing of the newly stented blood vessel.

Always consult your physician for more information.