Choose treatments wisely, as the less expensive path may result in a poorer outcome

THE following two patients turned up at the emergency department of the same hospital in a space of several weeks, each in the throes of an acute heart attack. They chose different treatment options – one costing way more than the other – and emerged with vastly different outcomes.

The expensive option

Mr A arrived at the emergency centre with chest pain and signs of a major heart attack involving the main heart artery, which supplies the main pumping chamber of the heart.

After discussion with the heart specialist, he opted for immediate opening of the heart artery with balloon catheters and insertion of stents, which are small metallic mesh tubes used to open up narrowed heart arteries. The procedure is known as Percutaneous Coronary Intervention or PCI.

In a major heart attack , every minute counts, as more and more heart-muscle cells die with each passing minute.

Mr A was brought immediately from the emergency department to the Invasive Cardiovascular Laboratory, where a PCI was performed successfully. He returned home a few days later and was able to return to his usual routine shortly after.

The ‘cheap’ option

Mr B also arrived in hospital with a major heart attack involving the main heart artery supplying to the heart.

Instead of an emergency PCI, he opted for the cheaper treatment – the infusion of a clot-dissolving agent, which is supposed to dissolve the clot.

As most heart attacks occur as a result of the formation of a blood clot blocking an already-narrowed heart artery, an infusion of a clot-dissolving agent has been the standard treatment – at least, before PCI became the standard. The use of clot-dissolving agents continues to be the practice in many hospitals, particularly those unable to provide acute PCI services. The success rate of clot resolution generally varies from 40 to 60 per cent, although it has been reported that success rates of beyond 80 per cent has been reported with the use of newer agents.

But clot-dissolving agents do present a one per cent risk of bleeding in the brain and a few per cent risk of bleeding elsewhere in the body.

Unfortunately for Mr B, the clot-dissolving medication failed to open up his blocked heart artery. As a result, a significant portion of his heart muscle progressively became damaged, compromising its pumping action.

He went into shock and his blood pressure plunged. Despite the attention he received in the intensive-care unit, his persistently-low blood pressure led to decreased blood flow to the kidneys, causing acute kidney failure.

The family then gave consent to open the heart arteries with stents. By then, the heart pump muscle was so extensively and severely damaged that, despite the surgery, his heart stayed weak and his blood pressure, persistently low.

In a last-ditch effort to save his life, an artificial heart device was implanted in him. This stabilised his condition, but his problems were far from over: he needed dialysis for his failing kidneys.

While attempting to save a few tens of thousands by going for the treatment option that cost some hundreds of dollars, the family’s decision unfortunately led to a significantly poorer outcome for the patient, who now has life-long disabilities which will affect his quality of life; he will also be burdened with long-term healthcare costs which are not insignificant for the average family.

Added to this, his initial bill of some hundreds of dollars for the clot-dissolving medication had ballooned to hundreds of thousands of dollars.

Making the best decision

In a major heart attack, both emergency PCI and infusion of clot-dissolving agents are acceptable options.

Emergency PCI can only be performed in hospitals with experienced heart specialists, highly-trained staff, facilities to perform the procedure and 24-hour service. Infusing clot-dissolving agents requires no special facilities and can be ordered by any heart specialist.

From a financial viewpoint, the cost of an emergency PCI could cost 10 times more, so clot-dissolving drugs may seem to be a more attractive option.

Unfortunately, the cheaper option does come with some trade-offs – its lower success rate and higher risk of bleeding in the body, including bleeding into the brain. In the case of Mr B, the “cheap” option cost him dearly in terms of his quality of life and the final cost of medical care.

In a major heart attack, there is no doubt that emergency PCI is the best choice for patients. While the “cheap” option of infusing clot-dissolving agents is routinely provided in hospitals which are unable to provide emergency PCI, one should go for the PCI if it is available.

The truth of it is, in medicine, one can rarely have “cheap and good” treatment options.

Making the optimal choice

Last but not least, when the decision has been made to proceed with an emergency PCI, wherever possible, one should opt for newer-generation stents which have polymers that are bioabsorbable.

Two commonly-available devices are the Bioabsorbable Vascular Scaffolds (BVS) by Abbot, and the Synergy stent by Boston Scientific. Both are American companies.

The BVS is almost completely made of a polymer material which has drugs and is designed to be completely absorbed by the body in three years; the Synergy stent is a cylindrical metallic mesh with a drug-polymer coating that is absorbed after a few months.

The greatest advantage with these newer-generation stents is that you can stop taking blood-thinning agents after a few months. The higher cost associated with the use of these stents is balanced by the significant advantage of not having to take blood-thinning drugs for the rest of one’s life. It means that when you need to have your teeth extracted or need surgery, you will not need to worry about the stents clotting up when you stop the blood-thinning agents before surgery.

It also means savings on the cost of consuming blood thinners for decades and avoiding their side-effects.

Therefore, choose wisely and opt for the optimal choice. Unlike cars, you cannot change to a newer version of the stents once they are implanted.