Speed Not Always of the Essence With Heart Cases in ER

MONDAY Nov. 10, 2008 -- No one doubts the need to rush to the hospital if someone is having a heart attack or even chest pains, but do doctors and nurses need to keep rushing once the person has been admitted?

New research suggests the answer is usually, "yes," but not always.

"The message to patients is to move as soon as possible to get into the hospital," Dr. Deepak Bhatt, of Brigham and Women's Hospital in Boston, said during a Monday news conference at the American Heart Association's annual scientific sessions in New Orleans. "This is a message to doctors and the health-care system. Once the patient is already hospitalized, do you need to rush them off to the cath lab within the next 24 hours, say, in the middle of the night on a weekend, or could you wait a day or two, which would be more convenient to the health-care system? The answer, at least in high-risk patients, was to go early."

"The key message from this study, in the majority of patients, there is no harm or no benefit of going early versus delayed," added study author Dr. Shamir Mehta, director of interventional cardiology at Hamilton Health Sciences Corp. and an associate professor of medicine at McMaster University in Hamilton, Ontario, Canada. "But risk stratification is key if the patient is at high risk. Our data do suggest that they benefit from early intervention. Exactly how risk stratification is used is subject to some debate."

Some had feared that going to the cath lab earlier rather than later might actually involve an "early hazard," meaning it might be dangerous, and that a "cooling-off" period with medical therapy might be advantageous, Bhatt said.

More than 3,000 patients with either a mild heart attack or unstable angina at 100 medical centers in various countries were randomized (after receiving routine therapy) to have a coronary angiography as soon as possible followed by percutaneous coronary intervention (PCI, or widening of the artery) or coronary artery bypass graft (CABG, or bypass surgery) no later than 24 hours after arriving at the hospital or to receive coronary angiography any time after 36 hours followed by PCI or CABG.

There was no significant difference between early and delayed invasive strategy for preventing death, heart attack or stroke.

But in a subgroup at highest risk (those with more severe heart attack), earlier was better for preventing death, heart attack or stroke.

There were no major differences in major bleeding or other safety concerns between the two groups.

"This is the major interventional cardiology trial being presented at AHA. It is also the largest trial on this topic, and the largest trial there has ever been on this topic," Bhatt said. "It is immediately relevant to patients, to doctors, and to the health-care system.

A second study found that an experimental oral clot-busting drug, rivaroxaban, was safe and resulted in a 6 percent absolute risk reduction for death, heart attack or stroke in patients with acute coronary syndrome (heart attack or unstable angina).

The study was the first to look at the effects of the drug in the arteries.

Existing drugs target the platelets in the bloodstream. Rivaroxaban targets a different part of the clotting process, called Factor X, said principal investigator Dr. Michael Gibson, chief of clinical research in cardiovascular disease at Beth Israel Deaconess Medical Center in Boston.

More information

The American Heart Association has more on acute coronary syndrome.

Posted: November 2008


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