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Follow-up rehabilitation boosts survival odds for angioplasty patients
Follow-up rehabilitation boosts survival odds for angioplasty patients
American Heart Association Rapid Access Journal Report
Study Highlights:
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Programs offering medical and lifestyle interventions can improve survival by nearly 50 percent after angioplasty.
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Lower death rates for patients in the cardiac rehabilitation programs can be seen in as little as a year of follow-up.
DALLAS, May 16, 2011 — Patients who undergo a procedure to unblock a coronary artery are more likely to survive longer if they participate in structured follow-up care, according to research in Circulation: Journal of the American Heart Association.
In their 14-year analysis, researchers discovered a 46 percent relative reduction in death from all causes in patients who participated in cardiac rehabilitation following angioplasty.
The study focused on patients treated with percutaneous coronary interventions (PCI), commonly known as angioplasty. Using data from a Mayo Clinic registry of PCI patients, along with telephone follow-up, the researchers examined outcomes for almost 2,400 patients who underwent a first PCI in the Rochester, Minn., area from 1994 to 2008, and survived their hospital stay.
In PCI, a physician inflates a balloon on a catheter tip to flatten plaque in the artery against the vessel wall. In many cases, they also insert a stent (metal-mesh tube) to prop the vessel open.
Forty-percent of the patients had participated in at least one session of a cardiac rehabilitation program, and participants attended an average of 13.5 sessions. Such programs can boost survival rates after heart attacks and systematically provide lifestyle interventions and treatments to improve recovery and long-term health of heart patients.
“Our findings show that patients who participate in cardiac rehabilitation following PCI have better long-term survival — about 50 percent better — than those who don’t participate in cardiac rehabilitation,” said Randal Thomas, M.D., M.S., lead author of the study and director of the Mayo Clinic’s Cardiovascular Health Clinic in Rochester, Minn.
The results accounted for smoking status, obesity, high cholesterol, family history, and certain medical conditions that might affect life expectancy, such as heart failure, kidney disease, or diabetes. The researchers noted a difference in death rates starting at one year of follow-up. Improved outcomes were among men and women, older and younger patients, and in patients who had undergone elective or non-elective PCI.
Almost 400 patients had subsequent heart attacks and 755 had additional procedures to open blocked vessels. In all, 503 patients died during follow-up; 199 of the deaths were validated as being cardiac-related.
Physicians and patients should understand that PCI is an important treatment, but not a cure for heart disease, and that ongoing interventions after PCI can help patients live longer, healthier lives, Thomas said. Cardiac rehabilitation programs include patient education, monitored and personalized exercise training, nutrition counseling, smoking cessation support, weight control therapy, and medical evaluations to track patient progress, symptoms, medication side effects and medication adherence.
“Cardiac rehabilitation programs are effective at improving recovery, quality of life and long-term survival because they help deliver the lifestyle and medication therapies that have been shown to slow or even reverse the process of heart disease,” Thomas said.
Because the study was observational rather than randomized, researchers used three statistical techniques to account for factors that might bias their results. For example, younger, healthier, more motivated patients who were already more likely to live longer were also more likely to participate in cardiac rehabilitation.
Although the study population was predominantly white, the results are consistent with other studies of cardiac rehabilitation in other patient subgroups with cardiovascular disease that have included larger groups of non-white patients, Thomas said. He said the study results should be further validated in other patient populations.
More than 600,000 PCI procedures are performed in the United States annually, according to the American Heart Association.
Cardiac rehabilitation is recommended in the 2005 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Guideline Update for PCI. But only about one-quarter of eligible U.S. patients participate, the researchers said. Gains in long-term survival would be substantial if all eligible PCI patients received cardiac rehabilitation, Thomas said.
Even in the unlikely event that the study results overestimate the true impact of cardiac rehabilitation and such services reduced deaths within five years by only 20 percent to 30 percent (instead of 46 percent, as found in the study), its impact on survival would still be substantial for patients after PCI, he said.
Most insurance companies cover up to 36 sessions of cardiac rehabilitation following PCI, heart attack and some other heart conditions. Medicare, which approved coverage of the programs for PCI patients beginning in 2006, typically covers 80 percent of the costs. Participation by patients following PCI appears to have increased since the Medicare change in 2006, although Thomas said many doctors and patients still remain unaware that coverage for cardiac rehabilitation is available following PCI.
Co-authors are Kashish Goel, M.B.B.S.; Ryan J. Lennon, M.S.; R. Thomas Tilbury, M.D.; and Ray W. Squires, Ph.D. Author disclosures and funding sources are on the manuscript.
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Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association’s policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content.
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Highlights of Article by Dr. Erik Hess et of Mayo Clinic ;CIRCOUTCOMES 2012
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Chest pain is the 2nd most common reason patients come to EDs across the United States
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Initial testing – including information obtained from the history, physical exam, electrocardiogram, and cardiac troponin – identifies > 98% of heart attacks
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To avoid missing a diagnosis of heart attack or pre-heart attack symptoms, emergency physicians often admit patients to observation units or to the hospital for extensive diagnostic testing, including stress testing
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This results in false positive test results, unnecessary exposure to radiation, and unnecessary downstream procedures such as stent placement in arteries of the heart
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Decision aids are evidence-based tools designed to educate and engage patients in decisions regarding their care
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We hypothesized that patients who were educated regarding their future risk for a heart attack and engaged in the decision of whether to be admitted to the observation unit for stress testing or to follow-up with a Mayo Clinic heart doctor in the next 72 hours would have greater knowledge about their short-term risk for heart attack, be more aware of the management options, and choose less intensive approaches to evaluation
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We randomly assigned 204 patients who came to the ED with chest pain and were being considered for observation unit admission to the decision aid or to usual care
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Decision aid patients:
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Had greater knowledge regarding their short-term risk for a heart attack
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Less frequently decided to be admitted to the observation unit for stress testing
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Had 4 times greater engagement in the decision making process
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Had no adverse events within 30 days of the ED visit
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Take home points
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Patients want to be educated and engaged in decisions regarding their care
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Once properly informed and engaged in treatment decisions, patients often choose less intensive treatment options
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Integrated health systems like the Mayo Clinic in which physicians collaboratively work together to provide ER patients ready access to outpatient follow-up have potential to improve the value of Emergency care
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Glucose, Insulin and Potassium (“GIK”) TO MINIMIZE IMPACT OF HEART ATTACKS BEFORE PATIENTS GET TO THE HOSPITAL
Study puts life-saving drugs in the hands of paramedics, decreasing rate of cardiac arrest and death from heart attacks
CHICAGO (March 27, 2012) — Paramedics can potentially reduce someone’s chances of having a cardiac arrest or dying by 50 percent by immediately administering a mixture of glucose, insulin and potassium (“GIK”) to people having a heart attack, according to research presented today at the American College of Cardiology’s 61st Annual Scientific Session. The Scientific Session, the premier cardiovascular medical meeting, brings cardiovascular professionals together to further advances in the field.
The study showed that patients who received GIK immediately after being diagnosed with acute coronary syndrome — which indicates a possible heart attack is either in progress or on the way — were 50 percent less likely to have cardiac arrest (a condition in which the heart suddenly stops beating) or die than those who received a placebo, although the treatment did not prevent the heart attack from occurring. The reduction in in-hospital cardiac arrest or death was a “secondary endpoint”, so statistically was not definitive, but was consistent with how GIK seems to work in experimental models of heart attack.
The effect was also present for patients with ST-elevation heart attacks, which require immediate treatment. For those patients, immediate GIK was associated with a 60 percent reduction in in-hospital cardiac arrest or death.
“When started immediately in the home or on the way to the hospital — even before the diagnosis is completely established — GIK appears not completely prevent any heart attack from occurring, but appeared in this trial to reduce the size of heart attacks and to reduce by half the risk of having a cardiac arrest or dying,” said Harry P. Selker, MD, MSPH, executive director of the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, who led the study with Joni Beshansky, RN, MPH, co-principal investigator and project director. “Acute coronary syndromes represent the largest cause of death in this country. GIK is a very inexpensive treatment that appears to have promise in reducing those deaths and morbidity.”
The cost of the treatment is about $50.
“Because the trial is the first to show GIK could be effective when used by paramedics in real-world community settings, it could have important implications for the treatment of heart attacks,” Dr. Selker said. Previous clinical trials have shown no consistent effect, likely because the GIK was given too late to help. This study, the “IMMEDIATE Trial,” was the first to test the effectiveness of administering GIK at the very first signs of a threatening heart attack, in the community, rather than waiting hours until the diagnosis was well-established at a hospital, as done in previous clinical trials.
“We wanted to do something that is effective and can be used anywhere,” said Dr. Selker. “We’ve done a lot of studies of acute cardiac care in emergency departments and hospitals, but more people die of heart attacks outside the hospital than inside the hospital. Hundreds of thousands of people per year are dying out in the community; we wanted to direct our attention to those patients.”
The researchers trained paramedics in 36 Emergency Medical Services systems in 13 cities across the country to administer GIK after determining that a patient was likely having a threatened or already established heart attack using electrocardiograph-based ACI-TIPI (acute cardiac ischemia time-insensitive predictive instrument) and thrombolytic predictive instrument decision support that prints patient-specific predictions on the top of an electrocardiogram. The paramedics used these predictions to decide if a patient would likely benefit from treatment. There were 911 patients randomized to receive either the GIK treatment or a placebo.
Administering GIK immediately also reduced the severity of the damage to the heart tissue from the heart attack. On average, 2 percent of the heart tissue was destroyed by the heart attack in people receiving GIK, compared with 10 percent in those who received the placebo. Although a significant proportion of suspected heart attacks are later determined to be false alarms (23 percent in this study), administering GIK does not appear to cause any harmful effects in such patients.
The research team will follow up with study participants at six and 12 months to evaluate the longer-term benefit of the GIK treatment.
This study was funded by the NIH’s National Heart, Lung and Blood Institute.
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Amazon.com 's Editorial Reviews
Angina: New Ways to Treat
Chronic Chest Pain
Part of the award winning public television series Healthy head
/Healthy Mind. It's one of the scariest medical symptoms for people who are generally healthy: a tightening, painful feeling in the chest known as Angina. In some cases this chest pain can be a serious warning that requires immediate treatment. But for the millions of people with chronic, stable angina the discomfort is something that can be readily managed with a variety of treatments. In this program we take a look at what generally causes angina, what can be done to prevent it and how it can be effectively treated with lifestyle changes, innovative drug therapies and medical procedures.
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Amazon.com Editorial Review:
Philips HeartStart Home Defibrillator (AED)
Be prepared for the unexpected.
When sudden cardiac arrest (SCA) strikes, the electrical system of the heart short circuits, causing the heart to quiver rather than pump in a normal rhythm. It typically results in the abnormal heart rhythm know as ventricular fibrillation (VF). It usually happens without warning and the majority of people have no previously recognized symptoms of heart disease. And it most often happens at home. For the best chance of survival from SCA caused by VF, a defibrillator should be used within 5 minutes. Yet, less than 1 in 20 people survive largely because a defibrillator does not arrive in time.
Just as seat belts or airbags do not save every life in a traffic accident, a defibrillator will not save every person who suffers a sudden cardiac arrest. Yet many lives could be saved if more people could be reached more quickly.
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