When Less May Be More

By John Langone

When people have a heart attack today, they are likely to be given powerful drugs to dissolve the clots that block the flow of blood to the cardiac muscle. But the drugs are generally used only to buy time until invasive procedures can be performed. These include angiography, the injection of a material into the coronary arteries to identify by X ray the 1 patient in 6 apt to have another attack; and balloon angioplasty, the threading into a blocked artery of a catheter with a tiny balloon on the end that presses plaque against the artery wall and widens the channel.

Now a new and controversial study has emerged to challenge this conventional treatment. Published last week in the New England Journal of Medicine, it concludes that immediate angiography and angioplasty, both costly and somewhat risky techniques, are unnecessary in most heart-attack cases. The 50-hospital study, sponsored by the National Institutes of Health and known as TIMI II (for thrombolysis in myocardial infarction phase II trial), involved 3,262 patients who had suffered apparent heart attacks. Within four hours of their attacks, all patients received a powerful clot dissolver, known as TPA (tissue plasminogen activator), along with heparin and aspirin to inhibit blood coagulation. Of the 1,636 patients in the invasive-strategy group, 928 underwent angiography and angioplasty within 18 to 48 hours after their attacks.

The results were surprising: after six weeks, the number of deaths and repeat heart attacks were similar for each group, a strong indication that there was no advantage in having angioplasty. The study's conclusions: angiography and angioplasty can be safely put off until patients show recurrent signs of a deficient blood supply to the heart muscle.

Not all cardiologists agreed with TIMI II's conclusions. Dr. Geoffrey Hartzler of the Mid America Heart Institute in Kansas City took issue because the study excluded patients age 76 and over, as well as anyone with a history of bypass surgery, heart-valve replacement, cerebrovascular disease, or other serious illness. "These were low-risk people, and it's a bad rap for angioplasty," he complained. "In fact, direct angioplasty alone, with no clot-dissolving drugs, is probably the single most effective treatment for acute heart attack."

Nonetheless, the trial has enormous implications for the routine care of heart-attack patients. Community hospitals with well-equipped coronary-care units, for example, could offer the relatively simple drug treatment and send . patients in real need of angioplasty or bypass to specialized centers. If cardiologists adopt TIMI II's conservative strategy, the estimated financial savings could total $200 million a year.