Editorial Comment
What Would I Want to Know If My Dad Had a Heart Attack?: Good Sense Versus Dollars And Cents* SAMUEL
M. BUTMAN.
MD,
FACC
Tucr,r,t. Anioll0
Evaluating the p&infarction
patient before hospital dis.
charge. If my father had a heart atta.P& what test or combi-
nation of tests would I want done as part of his postinfarction evaluation? Without question. I hope that he would agree to undergo coronary angiography and left ventriculography. That is easy for me to say because my father. who has never smoked and is about 80 years old. has a normal blood preswe and serum cholesterol level. Good news for him. and coed news for me. However, in this issue of the Jo&al, Candell-Rieraet al. (1) reasonably conclude that the roost effective noninvasive strategy for the postinfarction patient is a simple exercise test and a two-dimensional echocardiogram. There have been numerous reports (Z-5) on prognosticition for the survivor of a myocardial infarction and various clinical, noninvasive and invas& strategies have been shown to be useful in this regard. However. invasive cardiologists still favor their (oar) methods. those with a nuclear or echocardiographic bent use their favorites and various third party payers encourage the least costly approach. Only submaximal stress resting. which reassures the patient before hospital discharge and helps with the exercise prescription. is widely accepted and used. even though iti predictive value h¬ bken unquestioned (6). Exercise-provoked ischemia may be difficult to identify in the postinfarction patient. Rcsulls of exercise thallium-201 scintigraphy were negative in nearly 50% of the patients treated with recombinant tissue-type plasminogen activator in one recent series (7). Of concern are the characteristics of this potentially overlooked group of pzdients because they may be relatively young and have anatomic characteristxcs associated with a high risk of future events durine. follow-up (in lhat series 171. 47% hzd an anterior wall infarction and 39% had documented multivessel disease). The conclusions do confirm what others (7-9) have sug-
gested regarding the bmited additional clinical usefulness of expensive concomitant radionuclide imaging. except in wecilic circumstances. The present study. Foor of five patieets with acute myo cardial infarction survive to hospital discharge and perhaps an even higher proportion will do so with the more widespread availability and use of thrombolytic therapy l10.11). With thousands of patients surviving infarction, which is frequently their mitial cardiac event, it is imperative that we do not miss this opportunity to prevent future rehospitalirations. cardiac events and oremature death. Event rates after acute myocardial infarct& vary from series to series, but even in the study by Candell-Riera et al. (I) of “low risk” patients with a first infarction, there was a MIA complication rate in the 1st year of follow-up after hospital discharge. The studv samole reflects information from 33% to have three-vessel disease (IS). Follow-up WBE limited to I year, not 5 years as in these longer trials, and continued cr&ver to s&cal therapy shottli be expected. despite the inevitable need for invasive study and the occurrence of additional cardiac events in a significant number of patients. Clinieal elw to increased risk. General clinical clues that point to a significant increase in risk after myocardial infarction include a history of orevious myocardial infarction. recurrent myocardial &hernia after hospitalization, congestive heart failure and the presence ofcomplex or frequent ventricular arrhythmias (16). About 50% of all patients wilh infarction will have one or more of these problems. Is this not enough to suggest that the earliest possible delineation of coronary anatomy is imperative so that more definitive thempy can be addressed and planned if necessary, thereby avoiding future setbacks such as rehospitalin.tion for angina. recurrent infarction and the associated medical costs? Should we continue to spend money for expensive noninvasive tests aimed at selecting most. but not all. high risk patients and identifying most, but not all. low risk pattents
ofevents
JACC “0,. Novmlbel
IS. NO. 5 1, IFdyl.liiO-?
FDIT”Rlr\L
not in need of more aggressive tbcrapyl The test5 oscd I” this study were aimed at defining vcntr~olar foncuon and &dud myocardial ischemia in the hope of ldcntifying patients with multivessel coronary artery dnzase. Cardmc catheterization and coronary angiography prowde definwe and immediate definitions of both variables (17). Candell-Riera et al. (I) have shown that in the pauents studied. the best and most cost-effective nomnvasive swategy is an unencumbered exercise study and two-dimensional echocardiography. It seems owttable that strex echocardiogmphy may provide all the information in one sitting and at the same cost. The study does provide some reassoroncem that have a better idea of what to order for those patientr in whom angiognphy is not “indicated” or desirable. For my father, angiography would be desirable. If he has significant (25% reduction in lominal diameter) three-vessel or left main artery disease,he and would want to know as roan as possible so that he could undergo surgery to marimze hns longevity and functional ability (lHS1. Of course, that approach simply ignores medical costs and risk issues. confers that I generally dismiss the Ialter because. as oo angiographer. I do not think it is a significant problem relative to its clinical usefulneas in high volume laboratory. 0x1. on the other hand. is an impaunt and increasingly relevant problem. My father lbves in Canada and although he would not have to pay. his access to this invasive approach would be limited by design in Ihe government’s attempt to control health care costs. That is reality. Implications. We do need a uniform and cost-effective strategy that ideally can bc applied to all sorwors of myocardial infarction. The choices to consider are enher to continue to search for the ideal noninvaGve strategy. knowing that easily >50% will cross over to an invasive study. or to lower the cost of the initially more exprnswe strategy. In a more contemporary trial, in irs use of thrombolysis. only 4 of IO patients receiving “conservative” therapy m the Thmmbolysis in Myacardial Infarction (TIMI) II lrnl (18) did not require invasive study in the 1st year after infarction despite a program of routine follow-up exercise testing. Recurrent symptoms with or without rehospitalimtiun were by far the most cmmm ream cited. Can this inevirable need for angiography in the majority be avoided by better patient selection and algorithms’! The moot expensive strategy may actually be to perform noninvaswe tests on all patients and invasive procedures on come. knowing rhat during follow-up many more will rcquwe angiogrophy and that there will be inevilabk rehospitalizallons before delinilivc and often predictable therapy has been performed. In a cost analysis of a subgroup of patients enrolled in the National Cooperative Study Group of Uns,able Angina (19). the cost for patients who initially received medud tbernpy and who later underwent surgery wii) more than twce that for those initially treated surgically. Thor finding was very important because nearly 50% of those initially randomued
I now
I
I
a
B”TM*N COMMENT
WI
10 medical thrrapy underwent surgery wthin a relarively sho” period. The nonmvasive approach described by Candell-Riera et al. should be rsserved for patients who do not have any cimical suggcrtion of intcrmednre or high risk in the commg momhr or years as well as those patienrs in whom further mrervenlion IS undesirable or carries higher risk. The rest should bc considered for angiagraphy. Dad. ,f you have a heart attack, I do not want you tc have another one and 1 do not want you to die if I can help it. Today. the best uay 10 help you live long and well is to idcmify the best medical or surgical approach as soan as possible. hngiogaphy does that.
II)
References
I Cmdcll.Rl;r* 1.Pmnm,er-P$rdda G.caxe,, 1.eta,.C”mmp,,c”t.N Engl
JJr.Facron
Jhid,9s?:jw m+,~,O 1.Gibmn RS. lva1m DD.Craddock CB. 0alFTedich”“fmdiac OL”U
inerun~omplroledmso~la)mtararclion: a)r”r*cfr”i rwdycompaln3 prrdirrhlrb i\er(ne thalh”m.!01reintwaphyrnd coronaniang1a.w. pily CIIculdKm1983.68.3?1-36. i Gipln E. R&u” F. Di,,riChH. Uf04 P. He...@ H. RDl,J Jr. Fx!on .lrlu,r,cd ullh IrC”rrL”tmyaeardia, inrarcuan*ithi” one,Lal tier ilwtr m\“cardir,mfarcuanAm Hea” 6. F‘ucllchlr “F. PrrducST. AfwSd JE. on Pai, P. SkrraJanES CIcrcllulcIll”e “f pa,,l”B recownng(rammvacardval i”iarc,i0”.cum P‘“bl CardlotIYPaI,:,ww. 7 S”,,“” ,\I. Tami u. Slenlcanaal 1negire c,ertiseo3auium ,EIl Iii rhr praenceai _1
What Would I Want to Know If My Dad Had a Heart Attack?: Good Sense Versus Dollars And Cents* SAMUEL
M. BUTMAN.
MD,
FACC
Tucr,r,t. Anioll0
Evaluating the p&infarction
patient before hospital dis.
charge. If my father had a heart atta.P& what test or combi-
nation of tests would I want done as part of his postinfarction evaluation? Without question. I hope that he would agree to undergo coronary angiography and left ventriculography. That is easy for me to say because my father. who has never smoked and is about 80 years old. has a normal blood preswe and serum cholesterol level. Good news for him. and coed news for me. However, in this issue of the Jo&al, Candell-Rieraet al. (1) reasonably conclude that the roost effective noninvasive strategy for the postinfarction patient is a simple exercise test and a two-dimensional echocardiogram. There have been numerous reports (Z-5) on prognosticition for the survivor of a myocardial infarction and various clinical, noninvasive and invas& strategies have been shown to be useful in this regard. However. invasive cardiologists still favor their (oar) methods. those with a nuclear or echocardiographic bent use their favorites and various third party payers encourage the least costly approach. Only submaximal stress resting. which reassures the patient before hospital discharge and helps with the exercise prescription. is widely accepted and used. even though iti predictive value h¬ bken unquestioned (6). Exercise-provoked ischemia may be difficult to identify in the postinfarction patient. Rcsulls of exercise thallium-201 scintigraphy were negative in nearly 50% of the patients treated with recombinant tissue-type plasminogen activator in one recent series (7). Of concern are the characteristics of this potentially overlooked group of pzdients because they may be relatively young and have anatomic characteristxcs associated with a high risk of future events durine. follow-up (in lhat series 171. 47% hzd an anterior wall infarction and 39% had documented multivessel disease). The conclusions do confirm what others (7-9) have sug-
gested regarding the bmited additional clinical usefulness of expensive concomitant radionuclide imaging. except in wecilic circumstances. The present study. Foor of five patieets with acute myo cardial infarction survive to hospital discharge and perhaps an even higher proportion will do so with the more widespread availability and use of thrombolytic therapy l10.11). With thousands of patients surviving infarction, which is frequently their mitial cardiac event, it is imperative that we do not miss this opportunity to prevent future rehospitalirations. cardiac events and oremature death. Event rates after acute myocardial infarct& vary from series to series, but even in the study by Candell-Riera et al. (I) of “low risk” patients with a first infarction, there was a MIA complication rate in the 1st year of follow-up after hospital discharge. The studv samole reflects information from 33% to have three-vessel disease (IS). Follow-up WBE limited to I year, not 5 years as in these longer trials, and continued cr&ver to s&cal therapy shottli be expected. despite the inevitable need for invasive study and the occurrence of additional cardiac events in a significant number of patients. Clinieal elw to increased risk. General clinical clues that point to a significant increase in risk after myocardial infarction include a history of orevious myocardial infarction. recurrent myocardial &hernia after hospitalization, congestive heart failure and the presence ofcomplex or frequent ventricular arrhythmias (16). About 50% of all patients wilh infarction will have one or more of these problems. Is this not enough to suggest that the earliest possible delineation of coronary anatomy is imperative so that more definitive thempy can be addressed and planned if necessary, thereby avoiding future setbacks such as rehospitalin.tion for angina. recurrent infarction and the associated medical costs? Should we continue to spend money for expensive noninvasive tests aimed at selecting most. but not all. high risk patients and identifying most, but not all. low risk pattents
ofevents
JACC “0,. Novmlbel
IS. NO. 5 1, IFdyl.liiO-?
FDIT”Rlr\L
not in need of more aggressive tbcrapyl The test5 oscd I” this study were aimed at defining vcntr~olar foncuon and &dud myocardial ischemia in the hope of ldcntifying patients with multivessel coronary artery dnzase. Cardmc catheterization and coronary angiography prowde definwe and immediate definitions of both variables (17). Candell-Riera et al. (I) have shown that in the pauents studied. the best and most cost-effective nomnvasive swategy is an unencumbered exercise study and two-dimensional echocardiography. It seems owttable that strex echocardiogmphy may provide all the information in one sitting and at the same cost. The study does provide some reassoroncem that have a better idea of what to order for those patientr in whom angiognphy is not “indicated” or desirable. For my father, angiography would be desirable. If he has significant (25% reduction in lominal diameter) three-vessel or left main artery disease,he and would want to know as roan as possible so that he could undergo surgery to marimze hns longevity and functional ability (lHS1. Of course, that approach simply ignores medical costs and risk issues. confers that I generally dismiss the Ialter because. as oo angiographer. I do not think it is a significant problem relative to its clinical usefulneas in high volume laboratory. 0x1. on the other hand. is an impaunt and increasingly relevant problem. My father lbves in Canada and although he would not have to pay. his access to this invasive approach would be limited by design in Ihe government’s attempt to control health care costs. That is reality. Implications. We do need a uniform and cost-effective strategy that ideally can bc applied to all sorwors of myocardial infarction. The choices to consider are enher to continue to search for the ideal noninvaGve strategy. knowing that easily >50% will cross over to an invasive study. or to lower the cost of the initially more exprnswe strategy. In a more contemporary trial, in irs use of thrombolysis. only 4 of IO patients receiving “conservative” therapy m the Thmmbolysis in Myacardial Infarction (TIMI) II lrnl (18) did not require invasive study in the 1st year after infarction despite a program of routine follow-up exercise testing. Recurrent symptoms with or without rehospitalimtiun were by far the most cmmm ream cited. Can this inevirable need for angiography in the majority be avoided by better patient selection and algorithms’! The moot expensive strategy may actually be to perform noninvaswe tests on all patients and invasive procedures on come. knowing rhat during follow-up many more will rcquwe angiogrophy and that there will be inevilabk rehospitalizallons before delinilivc and often predictable therapy has been performed. In a cost analysis of a subgroup of patients enrolled in the National Cooperative Study Group of Uns,able Angina (19). the cost for patients who initially received medud tbernpy and who later underwent surgery wii) more than twce that for those initially treated surgically. Thor finding was very important because nearly 50% of those initially randomued
I now
I
I
a
B”TM*N COMMENT
WI
10 medical thrrapy underwent surgery wthin a relarively sho” period. The nonmvasive approach described by Candell-Riera et al. should be rsserved for patients who do not have any cimical suggcrtion of intcrmednre or high risk in the commg momhr or years as well as those patienrs in whom further mrervenlion IS undesirable or carries higher risk. The rest should bc considered for angiagraphy. Dad. ,f you have a heart attack, I do not want you tc have another one and 1 do not want you to die if I can help it. Today. the best uay 10 help you live long and well is to idcmify the best medical or surgical approach as soan as possible. hngiogaphy does that.
II)
References
I Cmdcll.Rl;r* 1.Pmnm,er-P$rdda G.caxe,, 1.eta,.C”mmp,,c”t.N Engl
JJr.Facron
Jhid,9s?:jw m+,~,O 1.Gibmn RS. lva1m DD.Craddock CB. 0alFTedich”“fmdiac OL”U
inerun~omplroledmso~la)mtararclion: a)r”r*cfr”i rwdycompaln3 prrdirrhlrb i\er(ne thalh”m.!01reintwaphyrnd coronaniang1a.w. pily CIIculdKm1983.68.3?1-36. i Gipln E. R&u” F. Di,,riChH. Uf04 P. He...@ H. RDl,J Jr. Fx!on .lrlu,r,cd ullh IrC”rrL”tmyaeardia, inrarcuan*ithi” one,Lal tier ilwtr m\“cardir,mfarcuanAm Hea” 6. F‘ucllchlr “F. PrrducST. AfwSd JE. on Pai, P. SkrraJanES CIcrcllulcIll”e “f pa,,l”B recownng(rammvacardval i”iarc,i0”.cum P‘“bl CardlotIYPaI,:,ww. 7 S”,,“” ,\I. Tami u. Slenlcanaal 1negire c,ertiseo3auium ,EIl Iii rhr praenceai _1
