Sickest heart patients less likely to get full care: experts

People in the greatest need of cardiac medications and interventions are less likely than moderately ill patients to get the full range of heart drugs and procedures — and it may be because they fail the "eyeball" test, a pair of cardiologists suggests.

'We have to put more emphasis and ensure by careful followup and tracking that these people get the treatment that they really need to take.' —researcher Dr. Arvind Koshal

Doctors may view these patients, the sickest of the sick, as too ill to benefit from proven treatments like catheterization or too depressed or unwell to deal with the hassle of more medication in what is likely already a multi-pill daily regime, Dr. John Spertus and Dr. Mark Furman argued in an editorial in Tuesday's issue of the Archives of Internal Medicine.

"As cardiologists ourselves, we recognize that patients who are more depressed or disabled may seem to be 'too sick' to warrant troubling them with the risk of invasive treatment or the hassle of more complex medical regimes," wrote Spertus, from the University of Missouri Kansas City, and Furman, from the University of Massachusetts Medical School.

In addition, they said, higher-risk patients are more likely to experience adverse side-effects due to the treatment.

Treatment paradox

Their editorial accompanies two studies by Canadian research teams that found further evidence to support what's called the treatment-risk paradox, the observation that patients with more advanced heart disease are less likely to be offered — or perhaps to adhere to— cardiac therapies and drugs that have been shown to be life-saving in medical trials.

One of the studies, by researchers at universities in Edmonton and Calgary, showed that only 56 per cent of higher risk patients were taking a statin drug, a cholesterol lowering medication, a month after having heart disease confirmed by an angiogram. In contrast, 63.5 per cent of lower risk patients were taking a statin a month after an angiogram.

By analyzing differences between the groups, the researchers found that patients who were depressed or whose lives were most restricted by their heart disease accounted for the difference.

Closer followup urged

They suggested that while there are two possible explanations— doctors didn't prescribe the drugs or patients didn't fill the prescriptions— they think it was probably the latter because the same effect was not seen for anti-angina medications used by the same group of patients.

"We have to put more emphasis and ensure by careful followup and tracking that these people get the treatment that they really need to take," said one of the authors, cardiac surgeon Dr. Arvind Koshal of the University of Alberta in Edmonton. He wasreferring to patients whose functional capacity is limited or who have depression.

The second study looked at rates of catheterization of heart patients over two periods of time —1999 to 2001 and 2002 to 2003.

The work, led by researchers from several Toronto teaching hospitals, found high-risk patients were half as likely to undergo catheterization than low-risk patients in the earlier period (27 per cent versus 48 per cent). In the latter period, rates in both groups rose markedly and the gap between the two groups narrowed somewhat (50 per cent versus 74 per cent).

Best treatment for the sickest?

Dr. Dennis Ko of Toronto's Sunnybrook Health Sciences Centre and the Institute of Clinical Evaluative Studies was an author of the 2004 study that coined the term "treatment-risk paradox."

Ko, who was not involved in either of the most recent studies,said while it's important to investigate who is getting which treatments and why, it's also important to note that it's not yet known if all therapies and drugs are appropriate for the sickest of the sick.

Dr. Paul Armstrong, a cardiologist at the University of Alberta who was not involved in this research, said some of the problem probably comes down to what he calls the three Cs of cardiac care: "cost, complexity and complications of medicines."

"Imagine being discharged from hospital after a threatened heart attack or a heart attack and being told you had to take five new medicines," he said. "And then going to the pharmacy without a drug plan and the pharmacist looks at you and says, 'That will be $275 for one month.' "