Altman, Lawrence K. "‘Standard' Heart Treatment is Hit and Miss," New York Yimes, 26
November 2002, p. F7.
CHICAGO - Important drugs, devices, procedures and operations to treat heart disease are
widely available, and American specialty groups have issued guidelines that generally agree on
their best use. So, ideally, heart patients should receive the same optimal therapy wherever they
are treated. In reality, they do not.
Findings from a small number of studies reported at a meeting of the American Heart
Association here last week highlighted a gap between what guidelines call for in preventing and
treating particular heart conditions and what doctors actually prescribe for them. Differences in
how often doctors apply guidelines for heart disease, which is the nation's leading cause of death,
have exposed serious flaws in health care.
The reasons cited for the gap are many and complex. One reason is that some hospitals and
doctors are less aggressive than others in carrying them out. A second reason is that even when
guideline-recommended drugs are prescribed, many patients do not comply with the instructions.
Still another reason is that guidelines are based on clinical trials in which most participants are
middle-aged. The relatively narrow focus can make it hard to extrapolate findings to the elderly
and children, limiting the usefulness of guidelines, which are published periodically in specialty
Using guidelines as a tool to measure patient outcomes in everyday practice is a new phase of
research for the relatively young specialty of cardiology. The heart group held its first scientific
meeting in 1925, 13 years after James B. Herrick of Chicago became the first doctor to diagnose
a heart attack in a living patient.
For many decades after that, effective therapies for heart disease were few. Doctors treated heart
patients by drawing on experience in their own practices and following the pontifications of
leading cardiologists. Therapies in that era differed drastically from today's - like advising long
periods of strict bed rest for heart attack patients instead of the current recommendations for
quick resumption of activity.
As more drugs and procedures were developed later in the 20th century, doctors increasingly
relied on clinical trials to provide evidence of the therapies' safety and benefits. Because few new
therapies were tested head to head, confusion existed about which regimens were best.
Not surprisingly, practice patterns varied widely. Critics challenged doctors to clarify what
worked and, just as important, what did not.
So the heart group and other organizations began to scrutinize findings from the growing number
of trials to develop guidelines for national use and to classify the importance of findings in the
As guidelines have standardized practice more than ever before, experience has led many doctors
to believe that greater application of the guidelines could improve patient comfort and health
statistics as much as development of a new drug.
Guidelines can only reflect the state of knowledge. As Dr. Sidney C. Smith Jr., the heart
association's outgoing chief science officer and a professor of medicine at the University of
North Carolina, said, "We have not reached the end of the rainbow in terms of understanding
which medications work and how best to apply them to make them work for all patients."
But Dr. Smith said he believed that future studies of the application of guidelines would show
that more doctors are using them as they better understand that their use correlates with improved
patient outcomes and cost reductions like fewer re-admissions to a hospital.
Dr. Eric D. Peterson of Duke University found a marked variation in the frequency with which
guidelines from the American Heart Association and the American College of Cardiology were
used in treating heart attacks in a study of 86,735 patients at 1,085 American hospitals between
July 2000 and March 2001.
The hospitals were ranked according to how often they followed the guidelines. The death rate
before discharge ranged from 17.6 percent in the 271 hospitals that lagged most in following the
guidelines to 11.9 percent among the 271 that led in following them.
A presumed reason for the difference in death rates was that patients did not benefit from the
application of several kinds of recommended therapies. Where the guidelines called for ACE
inhibitor drugs to reduce the risk of death, the study found their use was 40 percent in the
"lagging" hospitals compared to 70 percent in the "leading" hospitals. And where guidelines
called for cholesterol lowering drugs, the use was 58 percent in lagging hospitals compared with
80 percent in leading ones. Similarly, use of aspirin was 73 percent compared with 93 percent,
and efforts to stop smoking 7 percent compared with 65 percent.
Another study compared the care 32,000 patients received in nursing homes or elsewhere before
admission to hospitals for heart failure, the end stage of heart disease.
Dr. Edward P. Havranek of the University of Colorado at Denver led the study that found that
nursing home patients were less likely than patients treated elsewhere in the community to
receive ACE inhibitor drugs as recommended in guidelines. ACE inhibitor drugs can relieve
symptoms like shortness of breath to allow patients to feel more comfortable and function better.
Another reason for the gap is that patients may not follow guidelines even if their doctors do. As
a general rule, the larger the number of drugs prescribed, the less patients comply in taking them.
Earlier studies have shown that far fewer Americans take recommended drugs to reduce their
high blood pressure, which can lead to heart disease. Among the reasons is that many patients
reject the drugs because of their side effects and other perceived risks.
Some doctors do not follow guidelines because they fail to keep up with medical advances.
Others fail to communicate critical information from guidelines to patients well enough. Still
other doctors dismiss guidelines as cookbook medicine, partly in the belief that medicine is more
an art than a science. But as the lifesaving benefits of following guidelines becomes better
documented, such doctors are increasingly being challenged by the question: would they fly with
a pilot who did not use a checklist before takeoff?
Clearly, guidelines cannot completely replace physician judgment for many reasons. One is that
many patients, particularly the elderly, are afflicted with more than a single disease, and that
situation requires modification of guidelines. Another is that many patients do not fit the rigid
criteria used in selecting the participants in clinical trials, and disagreement may arise as to
whether the findings can be extrapolated to them. So the trials and guidelines do not answer all
the questions doctors face in everyday practice.
The willingness of doctors to follow guidelines starts in part with their own behavior. Long lines
outside a McDonald's in the convention center where the meeting was held and meals served at
lavish drug-company-sponsored events showed that many cardiologists did not heed the
association's dietary guidelines.