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Senior Citizen Health & Medicine
Death Risk Jumps by Nine from not taking Medicine
after Drug-Eluting Stent
Old age, low education, no
spouse, cost seen as factors for skipping drugs
June 12, 2006 Heart attack patients who stopped
taking antiplatelet drugs (which help prevent blood clots) within 30
days of receiving a drug-coated stent had nine times the risk of death
compared to patients who followed doctors orders. Shockingly, about 15
percent of those studied, who were supposed to take the medicine for
months, had stopped within the first month.
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Health & Medicine |
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An alarming one in seven patients in our study
stopped taking their antiplatelet medication within the first 30 days of
receiving a drug-eluting stent (DES), even though they were prescribed
the drugs at the time of hospital discharge and recommendations are to
continue them for a minimum of three to six months after the procedure,
said John A. Spertus, M.D., M.P.H., lead author of the study and
director of cardiovascular education and outcomes research at the Mid
America Heart Institute in Kansas City, Mo.
Researchers looked at the real-world use of DES in
heart attack patients and a class of drugs called thienopyridines that
work along with aspirin to help keep platelets in the blood from
clumping and leading to the formation of blood clots. Thienopyridines
include the drugs clopidogrel and ticlopidine. Blood clots can obstruct
a coronary artery, causing a heart attack.
Several studies have confirmed the benefits of DES
in preventing restenosis (reclosing of the artery that had been
treated). With stents, however, there is the potential problem of stent
thrombosis (blood clots forming inside the stent), which can be
associated with devastating consequences.
Antiplatelet agents, including thienopyridines,
reduce the likelihood of stent thrombosis. According to Spertus, no
previous studies have defined the frequency and consequences of
prematurely discontinuing thienopyridine therapy.
The risk of stent thrombosis with bare-metal stents
(stents not coated with a drug) decreases rapidly after two to four
weeks, and patients typically need thienopyridines for only about one
month. In comparison, with drug-eluting stents the risk of stent
thrombosis lasts for a longer period of time and patients with DES
require prolonged thienopyridine therapy (typically for several months).
In a 19-center study of 500 heart attack patients
(average age 61 years and 68 percent male) who received a DES and were
discharged with prescriptions for thienopyridines, 68 patients (13.6
percent) stopped their medication within 30 days. Those who stopped
were:
● older;
● less likely to have completed high school;
● less likely to be married;
● more likely to avoid health care due to cost;
● more likely to have pre-existing cardiovascular disease or anemia
when they arrived at the hospital; and
● less likely to have received discharge instructions about their
medications or be referred for cardiac rehabilitation.
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Drug-Eluting Stents Praised |
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In December of 2005, the American Heart
Association selected benefits of drug-eluting stents as one of the top
10 research advances in heart disease and stroke for 2005.
Benefits of drug-eluting stents - results from
RAVEL, was number four on the list and the news release said the following.
"After three years, the rate of major adverse
cardiac events (MACE) in patients treated with drug-eluting stents was
half the rate of patients treated with bare metal stents.
"At six months
and one year there were dramatic reductions in clinical events in
patients treated with the Cypher stent. At three years the MACE rate
(which includes death, heart attack or repeat procedures) was 15.8
percent in the drug-eluting stent group versus 33.1 percent in the
control group.
"The Cypher stent, which is made by Cordis
Corporation, a Johnson & Johnson Company, is coated with sirolimus, a
drug that reduces restenosis (re-blockage) in coronary arteries propped
open with a stent. The study enrolled 238 men and women, average age 60,
with newly diagnosed blockages in a single native coronary artery.
"At three years, outcome data from 113 patients
treated with sirolimus-eluting stents and 114 control patients were
available for analysis. The dramatic difference in the MACE rate is
largely due to a significantly lower rate of re-narrowing of treated
blockages."
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After one year, 7.5 percent of patients who stopped
their medication within the first 30 days had died compared to 0.7
percent of the compliant patients. In addition, 23 percent of those
who stopped their medication early were readmitted to the hospital,
compared to 14 percent of those who continued their medication, he said.
The rate of death was significantly higher and the
frequency of cardiac hospitalizations was almost twice as great over the
next 11 months among those who stopped their thienopyridines as compared
to those who continued them, Spertus said.
Researchers said previous studies under controlled
conditions found that the combination of DES plus three to six months of
antiplatelet medication effectively prevented restenosis for patients
with atherosclerosis.
Yet, clinical trials differ from real-world
practice where patients may have less intense follow-up or limited
access to the medications they need. Thats why it was important to
see how patients would fare under real-world conditions, including those
getting stents on a more emergency basis, such as for treatment of heart
attack, Spertus said.
The lack of a high school education was associated
with a 79 percent higher risk of stopping treatment, Spertus said.
This finding indicates that more patient education about why the
medicine is necessary could save lives."
Treatment decisions made at the height of clinical
urgency can have long-lasting consequences on the chronic care that
patients need in order to have the best possible outcomes. In this
case, prolonged use of thienopyridines after DES implantation for heart
attack treatment is clearly required for patients to get all the
benefits of reduced restenosis and to avoid the catastrophic
complication of stent clotting, he said.
Co-authors are Richard Kettelkamp, D.O.; Clifton
Vance, M.D.; Carole Decker, R.N., Ph.D.; Philip G. Jones, M.S.; John
Rumsfeld, M.D., Ph.D.; John C. Messenger, M.D.; Sanjaya Khanal, M.D.;
Eric Peterson, M.D., M.P.H.; Richard G. Bach, M.D.; Harlan M. Krumholz,
M.D., S.M. and David J. Cohen, M.D., M.Sc.
The study is reported in Circulation: Journal of
the American Heart Association. The research was funded in part by CV
Therapeutics, Palo Alto, CA.
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