Consider this situation: A patient comes into an emergency room with a horrible feeling of pressure in the chest or a squeezing pain that radiates down the arm.
Blood tests are done, and they find abnormal levels of heart muscle enzymes, indicating that a heart attack is in progress. An electrocardiogram suggests that the heart attack is mild. An artery is partly obstructed, but some blood is still getting through to the heart.
What should the doctors do? Until now, the answer seemed clear. They should rush the patient to a cardiac catheterization lab for angioplasty, opening the blocked artery with a balloon and, probably, a stent. The procedure carries a slight risk of causing a heart attack, but without it, heart specialists have believed, a mild heart attack could progress to a deadly one.
But a new study by Dutch cardiologists finds that another option is just as effective. Doctors can give patients powerful clot-dissolving drugs and drugs to lower their cholesterol and wait to see whether the chest pains go away. If they do, no angioplasty is necessary.
The results were a surprise even to the researchers, and they are so different from the standard procedures that some leading cardiologists say they do not expect them to change medical practice in the United States, at least not yet. But, these cardiologists say, the study was well done and the patients had state-of-the-art care.
"I really can't criticize it," said Dr. Eric J. Topol, chairman of the department of cardiovascular medicine at the Cleveland Clinic and one of those who does not expect many doctors to change their ways.
The study, led by Dr. Robbert J. de Winter, director of the cardiac catheterization lab at the Academic Medical Center in Amsterdam, involved 1,200 patients who had chest pains and had suffered mild heart attacks. Mild attacks were characterized by enzyme levels indicating muscle damage without the electrocardiogram pattern known as ST elevations, indicating a major attack.
Half the subjects were randomly assigned to immediate angioplasty. The rest were assigned to wait, receiving medical treatment. If their chest pains did not improve, they were sent to the catheterization lab. Eventually, about half of those assigned to wait ended up having angioplasty.
But the doctors first gave the medications time to work, and that is important, said Dr. William E. Boden, director of cardiology at Hartford Hospital, who wrote an editorial accompanying the paper. "Why subject everyone to a procedure they may not benefit from?" he asked.
"This study should be a bit of a wake-up call," Dr. Boden said. "Perhaps angioplasty and stenting everyone early and aggressively is a runaway freight train. This study would suggest that we perhaps reassess the situation."
Dr. Valentin Fuster, director of the cardiovascular institute at the Mount Sinai School of Medicine in Manhattan, noted that the aggressive opening of arteries for nearly everyone with chest pains had its roots in the 1990's. At first, it was just high-risk patients having major heart attacks who routinely had the procedure. That was appropriate, Dr. Fuster and others say. The arteries of such patients need to be opened immediately.
But doctors later began treating mild heart attack cases the same way. Some studies indicated that immediate angioplasty could help such patients, and the findings were a factor in convincing most cardiologists that it should be the standard of care.
Those studies began before the introduction of powerful clot-preventing and cholesterol lowering drugs given at the time of a heart attack, Dr. Fuster said. The new study took advantage of the newer drug regimens, and that, he suspects, is why it found no advantage to having angioplasty right away for a mild heart attack.
"What the paper is saying is that yes, one can often take a conservative approach," Dr. Fuster said. "That to me is the excitement."
Dr. Peter Libby, chief of cardiovascular medicine at Brigham and Women's Hospital in Boston, agreed. "I think this means it is a perfectly reasonable option to take the wait-and-watch stance," he said. "I am not against invasive strategies. But don't lull yourself into thinking you are prolonging the patient's life."
In the Netherlands, doctors are already changing, Dr. de Winter said. They learned about his results when he announced it last year at a conference, and many doctors no longer send all mild heart attack patients for immediate angioplasty. "If you think about one of the basic principles of clinical medicine," he said, "it is that you should not harm the patient if you are not absolutely convinced what you are doing has a benefit."
