Lessons of Heart Disease, Learned and Ignored
by Gina Kolata
Stents have recently been questioned for those who are just having symptoms like shortness of breath. In those cases, drugs often work as well as stents. But during a heart attack or in the early hours afterward, stents are the best way to open arteries and prevent damage. That, though, requires a cardiac catheterization laboratory, practiced doctors and staff on call 24 hours a day. The result is that few get this treatment.
“We now are seeing really phenomenal results in experienced hands,” Dr. Ornato said. “We can open 95 to 96 percent of arteries, and bleeding in the brain is virtually unheard of. It’s a safer route if it is done by very experienced people and if it is done promptly. Those are big ifs.”
The ifs were not a problem for Mr. Orr. His decision to go to Brigham and Women’s Hospital proved exactly right. But he did not know that when he chose the hospital — he chose it because his doctor was affiliated with Brigham.
A Need for More Angioplasty
Currently, 30 percent of patients who are candidates for reperfusion do not receive it, and of those who do, only 18 percent are treated with angioplasty, said Dr. Alice Jacobs, director of the cardiac catheterization laboratory at Boston University School of Medicine and a past president of the American Heart Association. Of the nation’s 5,000 acute care hospitals, Dr. Jacobs said, only 1,200 provide angioplasty.
Most hospitals, she said, cannot offer angioplasty because they do not have enough patients for a team of doctors to maintain their skills. An obvious solution would be to make heart attack care more like trauma care — sending patients to the nearest hospital that can provide angioplasty as quickly as possible. But that is not always easy, Dr. Jacobs said, because hospitals do not want to lose cardiac patients.
A major reason, she said, is financial. Hospitals are reimbursed by Medicare according an index that measures the acuity of medical conditions they treat.
“If your cardiac patients are transferred, your acuity index goes down, which lowers overall Medicare reimbursement for other problems like pneumonia and renal disease,” Dr. Jacobs said.
It is also difficult for patients who live in rural areas, where community hospitals are too small to offer angioplasty and larger hospitals that do offer it are hours away. Minnesota is experimenting with a program using helicopters to transport patients quickly. But for most rural patients elsewhere, angioplasty is almost an impossibility.
Dr. Antman suggests that heart disease patients ask their doctor if there is a hospital nearby that does angioplasty around the clock. If so, they might want to discuss with their doctor whether to ask that an ambulance take them there if they are having a heart attack.
It is the sort of advice that makes cardiologists nervous — they do not want to encourage patients to dictate treatment. But, Dr. Antman said, if it is feasible to get to an angioplasty-providing hospital within an hour, “in most cases that would be preferable.”
Getting the Proper Therapy
Opening an artery is only the start of treatment. The next part is at least as problematic: Patients have to get the right drugs, in the right doses, and have to take them for the rest of their lives.
“Care is getting a lot better,” Dr. Peterson said. “But the only caveat is that they are only really looking at, Did you get therapy? No one is looking too closely at, Did you do it right?”
For example, he said, a recent study found that heart attack patients were getting blood-thinning prescription drugs to prevent clots, as they should, but up to 40 percent were getting the wrong dose, usually one too high.
And even if every prescription were exactly right, as many as half of all patients do just what Mr. Orr did after his first heart attack. They stop taking many or all of their drugs.
Sometimes it is a matter of communication.
“The information did not get to the primary doctor and the primary doctor did not know to renew the prescription,” Dr. Peterson said. “When we talk to patients, they say: ‘No one communicated to me the importance of being on the medications long term. I thought I would only need them for three months, I thought it would be like an antibiotic. I thought they put in a stent so why do I need a drug?’ ”
But there may be more to it than ignorance. There also is the image those pills convey of a sick person.
Mr. Orr said he did not like to think of himself as someone who had to take a fistful of pills every day. Even the recommended daily aspirin seemed superfluous, he thought.
“I think I sort of pooh-poohed the notion that one tablet of aspirin each day would do anything,” Mr. Orr said.
What it does is make blood less likely to clot. In Mr. Orr’s case, Dr. Antman said, it is likely that when Mr. Orr was exercising on the cross-trainer, an area of plaque ruptured. Then a clot began to form in the area, eventually blocking the artery.
The problem was not exercise, which is good for people with heart disease, but Mr. Orr’s decision not to take his medications, Dr. Antman said. If he had been taking aspirin that clot would have had more difficulty forming and growing.
Dr. Antman has a message for patients: With a disease as serious as heart disease, those who take responsibility are often the ones who survive.
Having a heart attack, even if it turns out well, as his did, is a life-altering experience, Mr. Orr said.
His first heart attack, Mr. Orr said, “came out of the blue.” When he was discharged from the hospital, he was terrified that it would happen again when he was alone and unable to call for help. “I had a really hard time with it,” he said. “I only stayed in my own house for one night and then I moved to a friend’s house for two weeks.”
Now Mr. Orr plans to be serious about taking his medication and getting back to his diet and exercise program. He will call an ambulance if he ever has symptoms again. Still, he hates to think of himself as a patient. “I’m a little freaked out that I will have to take medication for the foreseeable eternity,” Mr. Orr said.
But the day after he got home from the hospital, he thought about what had happened.
“The gravity of the situation just sort of clicked,” Mr. Orr said. “I started to cry.”