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September 5, 2013

News Review From Harvard Medical School -- Angioplasty Faster, but Death Rates Stable

People having heart attacks are getting treatment faster in hospitals, a new study shows. But death rates have not dropped, the study found. Many people having heart attacks receive angioplasty. This procedure uses a tiny balloon. It is inflated inside an artery to open up a blockage. Hospitals have tried to improve how fast they get the procedure done after someone reaches the hospital. This is called "door-to-balloon time." The new study included nearly 100,000 people treated for heart attacks. Researchers compared 2 periods of time. Between July 2005 and June 2006, the average door-to-balloon time was 83 minutes. That dropped to 67 minutes in the year from July 2008 through June 2009. In the first year, 60% of the patients had a door-to-balloon time of less than 90 minutes. That jumped to 83% in the last year of the study. But death rates in the hospital or within 30 days remained the same. Researchers said the delay before someone gets to the hospital may be more important. Quick treatment also may lead to less disability, such as heart failure. The New England Journal of Medicine published the study. HealthDay news wrote about it September 4.

By Robert H. Shmerling, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

During a heart attack, a narrowed or blocked coronary artery prevents blood from flowing to a part of the heart. The artery needs to be opened up quickly. Otherwise, that part of the heart muscle dies.

In recent years, heart disease specialists have worked hard to reduce the "door-to-balloon" time for a person having a heart attack. This is the time between arrival at an emergency room and the inflation of a tiny balloon to open up a blocked coronary artery. This procedure is called angioplasty. It's the preferred treatment for people in the midst of a common type of heart attack. Most (but not all) research has shown that survival is better with shorter door-to-balloon times.

That's why efforts to improve the care of people with heart attacks have focused on reducing door-to-balloon times. The standard goal is 90 minutes or less. Many hospitals post their door-to-balloon times as a measure of quality. This allows patients, doctors and public health officials to compare -- and rank -- hospitals.

Yet a new study suggests that the enormous focus on door-to-balloon times may not be delivering the survival gains expected.

Researchers published a new analysis in this week's New England Journal of Medicine.They looked at the survival of nearly 97,000 patients who had first heart attacks between 2005 and 2009. During these years, door-to-balloon times plummeted.

Some of their findings were expected:

Door-to-balloon times were about 83 minutes in 2005-2006. They dropped to 67 minutes in 2008-2009.
Fewer than 60% of patients had a door-to-balloon time of 90 minutes or less in 2005-2006. More than 83% had reached this goal by 2009.

But there were surprising -- and disappointing -- findings as well:

The in-hospital survival of patients in this study (about 95% overall) did not improve between 2005 and 2009. About 90% of study patients were alive 30 days after their heart attack. This also did not change during the study period.
Even people with higher risk, such as those over age 75, did not survive more often in the later years of the study.

These findings raise the question of whether efforts to reduce door-to-balloon times are worth it. Other factors may be even more important. These factors might include the experience of the doctors and the time it took the patient to get to the hospital in the first place.

What Changes Can I Make Now?

Even the fastest door-to-balloon time will not be as effective as prevention. So take measures to reduce the chances you'll have a heart attack or need angioplasty.

The first step is to know the factors that increase the risk of coronary artery disease. Risk factors include:

A high total or LDL cholesterol level
A low level of HDL cholesterol (often called "good cholesterol")
High blood pressure (hypertension)
Diabetes
A family history of coronary artery disease at an early age
Cigarette smoking
Obesity
Lack of exercise
Male gender -- In middle age, risk is higher for men than for women. But risk rises for women after menopause.

You can take steps to lower your risk of heart attack. Here's what you can do:

Get regular exercise.
Choose a healthy diet.
Maintain a healthy weight.
Don't smoke or use other tobacco products.
Keep your blood pressure and cholesterol levels in a healthy range.
Take medicines, such as aspirin (for those at high risk).

If you have risk factors for heart attack -- and especially if you've had a heart attack in the past -- do some planning. Check out the hospitals in your area. Seek out information about quality of care and complication rates. Door-to-balloon times may be worth reviewing. But this research suggests that they may not be the most important measure of quality. Talk to your doctor about which hospital in your area is best for you.

What Can I Expect Looking to the Future?

You can expect doctors taking care of people having heart attacks to look critically at the results of this study. They'll want to know why short-term survival has not improved despite shorter door-to-balloon times. Future research and analysis may find answers to these questions:

Is it possible (or practical) to reduce door-to-balloon times further?
Will even shorter times lead to better results?
Is the time it takes a person to arrive at the hospital as important as (or more important than) door-to-balloon times?
Should other measures of quality be the focus of improvement efforts? For example, these might include doctor and hospital experience and the technique used to open up a coronary artery.

This new research suggests that door-to-balloon times may not be as useful a quality measure as we had thought. I hope that preventive measures will reduce the need for angioplasty in the future. Perhaps someday door-to-balloon times will actually become obsolete.