Circulation: In-hospital deaths more likely in patients with prior atherosclerosis

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Heart disease patients with previous atherosclerosis are more likely to die in the hospital and less likely to be treated with recommended therapies, according to a study published Aug. 3 in Circulation.

Researchers analyzed data from the American Heart Association's (AHA) Get With The Guidelines-Coronary Artery Disease database to determine whether compliance with quality of care treatment for heart disease was associated with the extent of prior vascular disease. They examined the records of 143,999 patients hospitalized in 438 facilities between 2000 and 2008.

Overall in-hospital mortality for all patients was 5.3 percent, but those who had previous artery blockages were more likely to die while hospitalized than those who had no prior vascular disease. They also were less likely to undergo surgery to clear their new blockages, had longer hospital stays and received cholesterol-lowering drugs, counseling to stop smoking and angiotensin-coverting-enzyme (ACE) inhibitors for left ventricular dysfunction less often.

"The results are surprising," said lead author Emmanouil S. Brilakis, MD, PhD, director of cardiac catheterization laboratories at Veterans Administration North Texas Healthcare System in Dallas. "Patients with prior atherosclerosis have a higher risk for complications compared with those without prior atherosclerosis. Therefore, one would expect them to be more likely to receive these evidence-based treatments."

However, researchers found that these patients were only more likely to receive aspirin within 24 hours of admission and a beta blocker prescription at discharge. Across the board, patients in the study received aspirin 92 percent of the time and a beta blocker prescription 94 percent to 95 percent of the time, regardless of prior vascular disease.

"All interventions examined in the current study are proven to improve morbidity and mortality and are included in the current AHA/ACC [American College of Cardiology] guidelines," Brilakis said. "However, some of the therapies, such as aspirin, are easier and cheaper to administer with very few contraindications and side effects compared with other treatments, such as cholesterol-lowering therapy and ACE inhibitors. This may explain why use of aspirin and beta-blockers in our study was similar in patients with and without prior atherosclerosis."

With some of the other treatments, the likelihood of their use was inversely related to the number of prior blockages. For example, patients with no areas of previous blockages received smoking cessation counseling 90 percent of the time, those with one area received the counseling 88 percent of the time; two areas 85 percent of the time; and three areas 79 percent of the time. Researchers found a similar decline in the administration of cholesterol-lowering drugs, from 89 percent for zero previous blockages to 77 percent to three prior areas of blockage.

Patients who had prior vascular disease were older and suffered from more diseases, which may be why they're given the recommended treatments less often, Brilakis said.

The investigators also found that patients with previous atherosclerosis were more likely to suffer from high blood pressure, diabetes and have had an earlier incidence of stroke and heart failure than those without prior artery hardening.

Brilakis said he hopes this study leads to more study on why the treatment difference exists and more patient and physician education to increase use of recommended interventions.

Get With The Guidelines is supported by the AHA in part through an unrestricted education grant from the Merck/Schering-Plough Partnership (which did not participate in the study's design, analysis, preparation, review or approval).