A Better Way to Treat Coronaries - Brief Article

Researchers at Duke University Medical Center, Durham, N.C., say a new heart attack treatment may hold promise: Give coronary patients a quick cocktail of drugs that dissolves clots and stops them from reforming, then, an hour later, perform angioplasty to clear plaque from heart arteries that are now open. This strategy--facilitated angioplasty--appears to offer a better outcome than thrombolytic treatment (clot-busting drugs) or angioplasty alone, or even medical therapy followed by angioplasty within several days, according to cardiologist E. Magnus Ohman.

Patients having a heart attack were treated within 60 to 90 minutes after arriving at one of the 61 participating hospitals in 14 countries. They were first given two doses of reteplase, a drug that breaks up blood clots, and a loading dose and infusion of abciximab, which prevents platelets from clumping to form new clots. Both drugs are approved for use in the U.S., although their combination is still in the early stages of testing.

The drug cocktail was followed an hour later by angioplasty, a procedure that presses plaque obstructions against the artery wall by inflating a small balloon from a catheter. Then, in most patients, a small girder-like stent was implanted into the artery wall to keep the artery open. The researchers found that, 30 days after the heart attack, 16% of patients who did not have facilitated angioplasty either had died, suffered another heart attack, or needed an urgent procedure to reopen the artery, compared with 5.6% who had facilitated angioplasty.

According to co-investigator Howard Herrmann, the rate of clinical success--defined as freedom from death, another heart attack, an urgent cardiac procedure, and bleeding--was 85% in the facilitated angioplasty group and 70% for other patients. "There appear to be many potential benefits to using this combination strategy to facilitate an early angioplasty."

"Unlike many treatments, facilitated angioplasty takes care of both clots and plaque," Ohman indicates. Cardiologists typically treat heart attacks with either thrombolytic drugs, such as reteplase, to dissolve offending clots, or primary angioplasty, to clear the plaque producing the heart attack. They don't often use both since studies from the 1980s showed the patients who received both treatments in quick succession fared worse. "But that was before we had a platelet inhibitor to add to the clot-busting drugs," Ohman points out. "These agents prevent platelets from aggregating, which would otherwise mean more clots."

Until now, physicians did not know whether using all three treatments (reteplase, abciximab, and angioplasty) together would increase the risk of bleeding. In fact, there was a reduced need for blood transfusion and a trend toward less bleeding in patients who received facilitated angioplasty, Herrmann says.

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