Although patients with congestive heart failure are much more likely to develop complications than other patients hospitalized with an acute myocardial infarction, they receive fewer potentially life-saving interventions, according to an article in the October 16th issue of the Journal of the American College of Cardiology.

"This article suggests that the heart failure patients are not getting the drugs and the thrombolytic therapy and the angioplasty that the lower risk patients are getting, even though they theoretically would stand to have more to gain because they are at higher risk," said Eric R. Bates, M.D., lead author of the study. "It suggests there is a treatment bias, that low-risk patients are getting the most aggressive therapy and high-risk patients are getting less than maximal therapy."

Dr. Bates and his American colleagues analyzed 190,518 records of patients included in the Second National Registry of Myocardial Infarction database, which contains more than 750,000 records of patients admitted to nearly 1,700 hospitals across the United States. Of the patients included in the current analysis, 36,303 (19.1 percent) had existing congestive heart failure at the time of myocardial infarction.

Of the patients with heart failure, 21.4 percent died while hospitalized, almost three times the death rate of patients who did not have preexisting heart failure (7.2 percent in-hospital death rate). The heart failure patients also suffered higher rates of second infarction, stroke, and other complications. However, the heart failure patients were less likely to receive aspirin, heparin, beta-blockers, or thrombolytic therapy. They were also less likely to receive angioplasty or other reperfusion procedures. The heart failure patients were more likely to receive angiotensin-converting enzyme inhibitors and calcium-channel blockers.

Although this database analysis cannot explain why heart failure patients were given less intensive treatment, Bates urged physicians to use the tools they have at hand to benefit the patients at higher risk. "If they have a 20 percent chance of dying and you can reduce that to 15 percent, then you've saved 5 lives for every 100 patients you treat, and that's a good use of resources," he said.

Gregg C. Fonarow, M.D., who was not involved in this study, agreed with that recommendation: "This study has immediate implications for physicians and nurses who care for patients with acute myocardial infarction, as it demonstrates that there is an urgent need to put systems in place to ensure that each and every patient with acute myocardial infarction is appropriately treated with those therapies proven to reduce the risk of mortality."

Bates noted that a focus of attention on infarction patients with cardiogenic shock has improved treatment for those high-risk patients, and he called for similar attention to be paid to patients with acute myocardial infarction and preexisting heart failure.

"Cardiogenic shock is present in about 7 percent of patients who come in with a myocardial infarction, and heart failure is present in about 20 percent of patients. We've talked a lot about cardiogenic shock on one end of the spectrum and patients without heart failure or shock on the other end of the spectrum, but there's really been very little attention focused on this large group of patients with a high rate of morbidity and mortality."