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Doctors Overuse Heart Treatment, Despite Guidelines

Heart Stent

Medical Animation Nucleus Medical Art

The controversial use of stents days after a heart attack has continued unabated in the United States, even after a landmark study and new guidelines said the pricey therapy does not help patients.

Just over half of patients who have survived at least 24 hours after a heart attack will have a stent — a small metal mesh tube — placed to open a blocked coronary artery, and that rate has not changed from 2005 through 2008.

The findings add to concerns about overuse of the heart devices, made by companies such as Boston Scientific, Abbott Laboratories, Medtronic Inc and Johnson & Johnson.

Stenting procedures cost the United States about $12 billion every year, and researchers say it is time doctors take responsibility for the nation's spiraling health costs.

"I think physicians have to rise to the challenge," said Dr. Judith Hochman, a cardiologist at New York University, who led the new work.

In 2006, Hochman published a study known as the Occluded Artery Trial showing that stents did not prevent any deaths or new heart attacks compared with drugs alone when inserted more than 24 hours after a heart attack into a totally blocked artery.

While the people who got stents did not experience any more side effects, the devices did rack up an extra $7,000 in net cost per person after two years, Hochman later found.

"After a day or so, whatever damage is going to be done was done already," she told Reuters Health. "The message is to seek medical care soon after a heart attack, and that is when stenting really helps."

Hochman's results became part of revised guidelines from the American Heart Association and other groups in 2007, which recommend against using stents more than 24 hours after a heart attack in stable patients.

Her new study, published in the Archives of Internal Medicine, is based on nearly 29,000 patients seen at 896 U.S. hospitals.

It shows that neither the 2006 trial nor the revised guidelines had a noticeable effect on stent use.
"Overall there was no change in practice," Hochman said. "I expected to see a change, so it was a big surprise and a disappointment."

600,000 STENTS A YEAR

Hochman's findings apply to about 100,000 Americans a year, suggesting that about 50,000 people are having the $20,000 procedure done unnecessarily every year.

That is in addition to thousands of stents inserted outside the context of emergencies such as a heart attack, according to a study from last week showing at least one in 12 of those procedures probably leads to more harm than benefit.

Each year in the United States, about 600,000 stents are inserted into ailing hearts where they prop open blocked arteries.

The stenting procedure, called percutaneous coronary intervention, or PCI, carries risks of complications like major bleeding or tears in the heart. After leaving the hospital, people also need to take clot-busting medications, which further increase the chance of bleeds.

Studies have found that many doctors rush to do PCI before using medications that might help stable patients just as well.

In an editorial, Dr. Mauro Moscucci of the University of Miami said Hochman's study had inadequate information about the severity of heart attacks, which might have justified the use of stenting in some cases.

Still, he said, it would have been reasonable to expect a reduction in the frequency of late stenting.

"While the debate on health care reform is ongoing, health care expenditures in the United States are continuing to escalate," Moscucci said.

"Thus we must heed the call to professional responsibility aimed at the elimination of tests and treatments that do not result in any benefit for our patients, and for which the net effect will be added costs, waste, and possible harm."

Another study in the same journal, published Monday along with Hochman's report, shows it is not uncommon to see new and better research challenge established conventions and treatments.
In that study, as many as 16 of the reports that appeared in 2009 in the New England Journal of Medicine, a leading medical publication, contradicted current practice.

But according to Hochman, getting doctors to drop a new treatment may be harder than getting them to take it up -- whether that's due to strongly held beliefs about its effectiveness, worries about medical liability or losing money, or patient expectations.

"We need a lot of changes in the system to control cost and this is just one example," she said.