Sickest heart patients less likely to get full scale care; may fail
'eyeball test'

TORONTO (CP) - 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.

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, of 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.

"These events are visible to the treating physician early and form a
powerful incentive to discourage invasive care," they said.

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.

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.

"Perhaps doctors should be targeting at time of discharge or maybe
have a closer followup to make sure that patients who fall in this
category - either the ones whose functional capacity is limited . . .
or who have depression, which is quite often an associated problem
with these diseases - that 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," one of the authors, cardiac surgeon Dr.
Arvind Koshal of the University of Alberta, said from Edmonton.

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).

Despite the narrowing, the treatment-risk paradox was still evident,
they said.

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."

He 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.

"I think . . . we've identified a problem that you know a lot of these
high-risk patients are not getting it. But we haven't really gone to
the next step to say: Well among these high-risk patients, who are the
ones that should get it, who are the one's that shouldn't?" said Ko,
who was not involved in either of the studies.

Dr. Paul Armstrong, a cardiologist at the University of Calgary, 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. 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,"
said Armstrong, who was not involved in this research.

"Those are the sorts of 'walk in the moccasins' real issues here."