Many Heart Attack Patients Don’t Get Best Emergency Treatment

Far more of today’s heart attack patients receive emergency angioplasty treatment or clot-busting drugs to re-open their clogged heart arteries than even a decade ago, a new study finds.

But 10 percent of patients who could benefit from this urgent treatment – which is known to save lives and prevent lasting damage to the heart muscle – don’t get it at all, the study shows.

And the chance of missing out on lifesaving emergency treatment was highest among those patients whose heart attack symptoms don’t include typical symptoms like chest pain, those who didn’t reach the hospital until six or more hours after the start of their attack, women, people over age 75, and non-white people.

The study, published in the American Journal of Medicine by a team led by cardiologists from the University of Michigan Cardiovascular Center and the Yale University School of Medicine, is based on data from 238,291 patients who had had a type of heart attack for which this therapy is appropriate between 1994 and 2003.

It’s the most current and comprehensive look at the use of emergency “reperfusion” – a term that describes treatments that can break up blood clots and other blockages in the tiny blood vessels of the heart and restore blood flow to the heart muscle.

In the ten-year study period, the percentage of patients who could have received emergency reperfusion but didn’t declined from more than 20 percent to 10 percent – a notable achievement that the authors attribute to the increasing evidence of the benefit of emergency angioplasty, and the rise in the availability of the treatment at American hospitals and concerted national efforts to improve care.

The database used for the study, called the National Registry of Myocardial Infarction, includes detailed information about each patient’s condition that can be used to determine if they would meet the criteria to receive emergency angioplasty or treatment with fibrinolytic (clot-busting) medications.

But it’s those details that reveal the troubling gap between the number of patients who could have received the treatments, and those who actually did.

“We may never be able to get to 100 percent, but 10 percent of eligible patients going untreated is still too many,” says first author Brahmajee Nallamothu, M.D., MPH, assistant professor of cardiovascular medicine at the U-M Medical School. “We hope our study highlights the opportunities to improve care and particularly some of the “at-risk” subgroups still less likely to receive reperfusion therapy despite eligibility, so that we can focus our clinical efforts on them.”

Adds senior author Harlan Krumholz, M.D., S.M., “This study has good and bad news. We have definitely made progress in treating appropriate patients, but our findings indicate that we need to improve further to be sure that no patient who could benefit from this treatment is missed.” Krumholz is the Harold H. Hines, Jr. Professor of Medicine in the Section of Cardiovascular Medicine and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation.