Heart treatment guidelines often not followed

NEW YORK (Reuters Health) - More than a third of Americans with heart disease may not be getting “guideline-based” treatment for their disease.

Researchers found evidence that patients with coronary artery disease (CAD) -- in which plaque build-up starves the heart of its blood supply -- receive more recommendations for angioplasty and fewer recommendations for coronary artery bypass surgery (CABG) than indicated by current guidelines.

CABG, also known as “open-heart surgery,” is a procedure in which the rib cage is spread open and a section of a healthy blood vessel is attached to “bypass” the blocked section of the coronary artery and improve the blood supply to the heart.

Angioplasty is a less invasive procedure used to widen narrowed or blocked arteries. A thin tube, or catheter, is threaded through a blood vessel to the affected area and a small balloon is inflated to open the blockage.

Which therapy is appropriate for a particular patient is outlined in “evidence-based” guidelines developed jointly by the American College of Cardiology and the American Heart Association.

“The guidelines are what a multidisciplinary and representative group of cardiologists and surgeons have determined is the best intervention given the patient’s specifics,” Dr. Edward L. Hannan, of the State University of New York in Albany, noted in a telephone interview with Reuters Health.

Hannan and his associates wanted to know whether cardiologists were following existing guidelines for use of angioplasty and CABG. They conclude in a report published this month in the journal Circulation that, too often, the answer is “no.”

Hannan’s team looked at data gathered between 2005 and 2007 at 19 hospitals in New York State involving 10,333 patients treated for CAD. They compared the treatment the professional guidelines called for according to the patient’s medical status with the treatment recommended by the physician.

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They found that 94 percent of patients for whom angioplasty was indicated by the guidelines were recommended for angioplasty. But only 53 percent of patients for whom the guidelines called for CABG were recommended for the surgery; 34 percent of these patients were recommended for angioplasty.

For patients who had indications for both CABG and angioplasty, 93 percent were recommended for angioplasty and 5 percent for surgery. Among patients for whom neither CABG nor angioplasty was indicated by the guidelines, 6 percent were recommended for CABG and 21 percent for angioplasty.

Hannan and his colleagues say they were intrigued by the frequency with which angioplasty was recommended even though the guidelines suggested surgery. What’s also concerning is that the tendency to recommend angioplasty was “more accentuated” at hospitals with angioplasty capabilities, the authors note.

The finding that angioplasty appears to be recommended more often than indicated is “particularly important,” Hannan and colleagues say, given that some recent studies have found CAGB surgery outcomes to be better than angioplasty outcomes for some patients.

He and his colleagues plan to follow these patients over time to determine how patients fared after getting treatment different from that recommended in the professional guidelines.

One problem, according to Hannan, is that current guidelines are “kind of complicated and confusing.” He and his colleagues favor multidisciplinary involvement in CAD treatment decisions.

In a written commentary, Dr. Raymond J. Gibbons of the Mayo Clinic says the study raises valid concerns, particularly about the way medical tests and procedures are paid for in the current US healthcare system.

Of greatest concern, he writes, is the possibility that “the recommendations for (angioplasty) in patients indicated for CABG reflect a ‘grow the business’ and ‘make it up in volume’ mentality in response to declining reimbursement rates.”

The current reimbursement system “favors tests and procedures,” he notes, and six angioplasties can be performed in the time it takes to complete one bypass.

If these concerns are not addressed, Gibbons told Reuters Health: “We run the risk of losing the confidence of patients” and prompting regulatory interference, “which I personally believe would be a disaster.”

SOURCES: Circulation, online January 4, 2010