Drugs or balloons? A rancorous debate over how to treat heart attacks, already a plot twist in the hospital drama “ER,” is sharply dividing one of the world’s largest gatherings of cardiologists.
On “ER,” the dialogue went this way:
Young resident: “Acute infarct. I just started TPA.”
Senior doctor: “Without consulting me? He should go to the cath lab for angioplasty.”
Judging from talk in the formal sessions and hallways at this week’s meeting of the American College of Cardiology, similar exchanges are common in hospitals across the United States, or soon will be.
At issue is the better way to quickly get rid of blood clots that cause heart attacks. Disintegrate them with clot-dissolving drugs like TPA? Or push them aside with tiny balloons?
At stake are lives and money.
During the past decade, clotbusting drugs have emerged as the front-line treatment for heart attacks, used on 180,000 Americans at a cost of $350 million annually. If given soon enough, they can break up blockages in the heart’s arteries, preventing permanent damage or death.
But now an approach called primary angioplasty is challenging the dominance of these drugs.
Angioplasty is already a mainstay of heart therapy. It is used on about 420,000 Americans each year to relieve chest pain in patients, nearly all of whom were not having heart attacks. Doctors thread a catheter into clogged heart arteries and briefly inflate a tiny balloon that squeezes open the blockage to restore blood flow.
In its new application, some doctors are performing angioplasty as an emergency procedure within an hour or two after the heart attack patient arrives at the ER.
The latest findings presented at the cardiology meeting, attended by about 25,000 people, suggest that primary angioplasty is better, safer and cheaper than clot-busters.
“The data are overwhelming that it is a superior strategy,” said Dr. William P. O’Neill of William Beaumont Hospital in Royal Oak, Mich. He described primary angioplasty as a breakthrough that has “changed the natural history of this disease.”
Sometimes, angioplasty is used as a backup if the clot-busters fail, but not the other way around, because angioplasty succeeds more than 90 percent of the time.
O’Neill’s latest findings, based on 1,099 patients at 32 hospitals in five countries, found that half of run-of-the-mill heart attack patients fall into a low-risk category that does amazingly well with angioplasty.
Their death rate is an astoundingly low four-tenths of 1 percent. And they can safely be sent home from the hospital just three days after their attacks, rather than staying the standard week or more while receiving clot-busters. This could mean substantial savings, even with the cost of angioplasty, which runs between $15,000 and $20,000.
Patients are considered at high risk when they are over 70 or have several diseased arteries or weakly beating hearts. They, too, do impressively well with angioplasty, with a death rate was just under 4 percent.
By contrast, about 6 percent of patients die after getting clot-dissolving drugs. About 3 percent suffer strokes when the treatment accidentally triggers bleeding in the brain. Angioplasty does not carry this risk.
“This has profound implications for clinical practice,” said Dr. Jeffrey Isner of Tufts University in Boston. “It should be regarded as good news. It suggests the opportunity of a very aggressive approach getting people out of the hospital after a heart attack.”
However, those who have spent much of their careers on clot-dissolving drugs are skeptical, at best.
“Some of these investigators have been overstating the case based on small numbers of patients,” said Dr. Eric Topol of the Cleveland Clinic, who helped pioneer the use of clot-dissolving drugs.
Only about 3,000 patients have been formally studied in reviews of primary angioplasty, compared with 150,000 in experiments with clot-busters.
Furthermore, the latest mortality figures reported with angioplasty seem perhaps too good to be true.
“They are acting like patients are almost made immortal by this,” Topol said.