NEJM: Drugs rival stenting in outcomes for delayed MI treatment, and at lower cost

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Many patients who receive drugs plus stents as delayed treatment for a heart attack have equivalent outcomes to using drugs alone; also the drug option is cheaper and there is no meaningful long-term difference in quality of life between the two options, according to results from the Occluded Artery Trial (OAT), which appeared in the Feb. 19 issue of the New England Journal of Medicine.

"The finding is just one more reason to question the use of routine stenting in late-treatment patients when cheaper, less invasive options are just as effective," said the study's lead author Daniel Mark, MD, a member of the Outcomes Research Group at the Duke Clinical Research Institute in Durham, N.C.

Researchers studied the quality of life and medical expenses of patients enrolled in OAT, which compared optimal drug treatment with drugs plus stenting among patients who had suffered a heart attack, but who received treatment days or even weeks after the first symptoms appeared.

Each year, about one million people in the U.S. suffer heart attacks. Studies show that the sooner treatment begins, the better-ideally, within a couple of hours. But in real life, about one-third of all patients are treated more than 12 hours after the first symptoms appear, according the authors.

In the initial OAT trial that evaluated 2,166 patients, researchers showed that optimal medical therapy and medical therapy plus PCI were equally effective in stable MI patients whose treatment is delayed for days or even weeks. Now, in examining quality of life issues in the two groups, investigators said that while PCI does indeed produce modest benefits in reducing chest pain and improving functioning, those benefits do not last.

Mark and colleagues examined how patients felt about their lives and the cost of the two approaches among 951 patients in the original study. Participants included patients who had suffered a heart attack anywhere from three to 28 days prior to enrollment, who had a completely blocked artery but who were clinically stable and experiencing no chest pain. All of the enrollees received optimal medical therapy, but half were randomized to receive PCI as well.

Investigators found that at four months, patients in the PCI group reported less chest pain and scored higher on the DASI. But the differences were small and disappeared over time, according to the authors. By the end of the study, patients in the medical therapy group appeared to be doing just as well as those in the PCI group.

The researchers also compared the costs of the two treatments and the use of healthcare resources among a subgroup of patients in the U.S. They found that during the first month of treatment, members of the PCI group stayed in the hospital 1.2 days longer than those in the medical group, mostly reflecting longer time in intensive care. They also found that the mean cost for hospital and physician care during the first 30 days after starting treatment was $22,859 for the PCI group and $12,683 for the medical therapy group. Overall, cumulative two-year costs were approximately $7,000 higher in the PCI group.

"While it may seem that going an extra step in opening up clogged arteries even days after a heart attack, we know that clinically, it doesn't seem to offer the advantages we expected," Mark said. "Coupling that with the higher cost, we now know that adding PCI to standard medical care in opening blocked arteries more than a day after a heart attack is not good value. In an era when the high cost of healthcare is the subject of intense debate, this study offers us one way we can offer high quality care for less money."

"All heart attack patients should seek treatment right away to limit damage to the heart muscle," noted Elizabeth G. Nabel, MD, director of the National Heart, Lung, and Blood Institute (NHLBI), which supported the study. "For the one-third of patients who do not receive immediate care--but who are otherwise stable--we have greater evidence of how treatments really affect them. Medical care is not just about immediate results and survival, but it is also about providing good quality of life and minimizing medical costs."