Aspirin, angioplasty cut state heart attack deaths

By Stephen Smith, Boston Globe Staff  |  June 26, 2005

Deaths from heart attacks in Massachusetts dropped by 24 percent in eight years, according to state data analyzed by The Boston Globe. That translates into 1,200 fewer lives lost annually -- even though studies show that the number of heart attacks has not declined.

Doctors credit this success story to technological breakthroughs that allow specialists to use tiny medical tools to unclog choked arteries, as well as more aggressive use of aspirin, the age-old panacea.

''When you start to add all these things up, you get a dramatic improvement in outcome in patients who've had heart attacks," said Dr. Joseph P. Carrozza, a top cardiologist at Beth Israel Deaconess Medical Center in Boston. ''Not only do they live longer, but they have better quality of life."

''Twenty years ago, if you had a heart attack, you were told to pretty much lead a sedentary life," Carrozza added in an interview. ''Now, there's been a whole across-the-board reappraisal of how we treat heart attack patients."

Nationwide, the number of people succumbing to heart attacks has also decreased, although at a somewhat slower pace than in Massachusetts, according to figures from the US Centers for Disease Control and Prevention. In most measures of health, Massachusetts citizens tend to fare better than those elsewhere, according to the national average.

Heart attacks, among the prevalent causes of sudden death and disability, happen when blood and oxygen to part of the heart is blocked, most often by a clot forming in a coronary artery.

According to state figures on death certificates, 4,886 people in Massachusetts died from heart attacks in 1994. By 2002, the latest year for which figures are available, deaths had declined to 3,706. Cardiology specialists said that their experience with treating patients strongly suggests that the decline in deaths continued in 2003 and 2004.

Federal figures have found that the total number of heart attack deaths in the United States dropped from about 222,000 in 1994 to about 180,000 in 2002.

The year 1994 provides a good line of demarcation for tracking trends in heart attack deaths.

''The biggest difference between now and 1994 is that we are now completely convinced that the key to saving patients' lives and improving function after a heart attack is to get a blood vessel opened as fast as we can," said Dr. Scott Solomon, director of noninvasive cardiology at Brigham and Women's Hospital. ''That was a concept that was really just being introduced in the late '80s and early '90s."

The change in the treatment of heart attacks has been swift and sweeping. When Christopher Cannon was training less than two decades ago in New York, this, he said, is what happened when patients clutching chests showed up in the emergency room: ''The heart attack patients that came in got morphine and nitroglycerin. They didn't even get aspirin."

Today, patients treated for heart attacks at a hospital such as Brigham and Women's, where Cannon is a cardiologist, are routinely sent for a minimally invasive operation to have coronary blockages removed, with a little scaffolding installed to assure that weakened arteries don't collapse.

In that procedure, known as angioplasty, patients are taken to a room called a catheterization laboratory. There, specialists use medical snapshots to look at the arterial highways of a patient's body, how traffic is flowing, and where blockages occur.

Then, a specialist makes an incision, threads a small balloon through a blood vessel to where the blood flow is stopped, uses the balloon to clear the blockage, and installs a stainless steel scaffold -- called a stent -- to keep the vascular wall from collapsing.

The use of stents is now commonplace. And makers of stents have begun coating them with a drug designed to prevent blockages from recurring.

But in the early days of angioplasty, not everybody thought it was a good idea to use the technique as a first-line approach for heart attack patients, even if the surgery wasn't especially invasive.

One camp of specialists advocated clot-smashing medicines called thrombolytics. A significant share of patients, though, couldn't be given those drugs because they were prone to suffer potentially lethal bleeding complications.

''Some of us were viewed as pariahs in the mid-'90s because we said use angioplasty instead of the clot-busing medication," Carrozza said.

Even as angioplasty came into wider use, heart specialists began to recognize the potential of a host of drugs in the quest to rescue patients suffering heart attacks.

There is, of course, aspirin, which helps thin the blood but which does not include some of the risks associated with thrombolytic drugs. And there are pills called beta blockers, which originally came into routine use as a way of treating high blood pressure and other cardiovascular conditions. When a patient suffers a myocardial infarction, generally known as a heart attack, it's as if a huge electrical storm has descended on the patient's heart. Beta blockers help to still the storm by slowing the heart and maintaining its rhythm.

Another class of pills known as ACE inhibitors can help prevent the heart from becoming misshapen after a heart attack, as healthy muscle struggles to compensate for dead muscle.

Like beta blockers, the ACE drugs have been around for a while and are widely used to treat hypertension.

While progress in caring for heart attack victims is undeniable, there is some dispute about whether improved medicine or technology deserves more of the credit. There is a tension -- subtle, but sure -- between specialists who come down on the side of the surgical approach and those who are proponents of medicine-based approaches.

Dr. Gray Ellrodt, a cardiologist and the chairman of medicine at the Berkshire Medical Center, acknowledged that angioplasty helps save lives.

''Everybody's tempted to say, 'Look at all the cool stuff we can do in the cath lab. This must be what's saving people,' " said Ellrodt, a leader of the American Heart Association. ''But a lot of our success is probably due to increased use of aspirin at the time of hospitalization and at the time of discharge and increased use of beta blockers. When you really dig in, it's very simple blocking and tackling stuff."

The landmark Worcester Heart Attack Study, begun in 1975, found that the need for comprehensive cardiac care won't go away soon. Robert Goldberg, director of the project to track patients and their treatment, said that through the 1990s and into this decade, the rate of first-time heart attacks remained unchanged in Central Massachusetts. During that period, heart attack deaths in the Worcester area declined substantially, according to the study, run by the University of Massachusetts Medical School.

''That's very impressive," Goldberg said. ''The patient population is much older, they have much more diabetes, more heart failure. And yet their . . . prognosis is getting better."

But specialists fear that the decline may not continue.

For one thing, researchers know that patients who have one heart attack stand a much greater chance of suffering future cardiac problems, especially congestive heart failure. So, with more heart attack victims surviving, there's an ever-larger pool of patients who are at risk of having fatal myocardial infarctions.

Then there's the rise in obesity, diabetes, and other medical conditions strongly associated with heart disease.

Further complicating matters: Despite campaigns designed to prod patients to seek help in the early minutes after pain and shortness of breath begin to take hold, the Worcester Heart Attack Study and other research articles have reported that patients still wait too long to acknowledge the signs of an attack.

''They don't want to have a heart attack," said Dr. Eric Topol, chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic in Ohio. ''They think it's indigestion or muscle pain -- anything but a heart attack. They tough it out, but it keeps getting worse until they finally call 911. During that delay, there's typically a fair amount of damage to the heart muscle."

Joe Bennett says he's been one of those patients who hesitated to get help fast enough. Bennett, who lives in Dudley, had his first heart attack in 1994. Then there was the second, in 1996, and a third, in 2000, and a fourth, in 2002.

In 2000, he says, he didn't seek help until ''the pain got to the point I just couldn't tolerate it." But, even then, he survived.

Bennett, who's 69 and retired, has had bypass surgery, has had multiple stents implanted, and has taken more medicine than he can remember. There's a long history of heart disease in his family, especially on his mother's side.

Bennett credits his survival to his battery of doctors at UMass Memorial Medical Center, to advances in treatments, and to his own determination to watch his three sons thrive as adults and, now, to see the birth of his first grandchild.

''I'm proof," Bennett said. ''I've survived a lot of stuff. People say, 'How the heck did you make it through all of this?' I tell them, 'I look forward to things.' "