Outcomes/Effectiveness Research

Angiography recommendations appear to identify patients who are likely to benefit from the procedure

Doctors vary widely in their use of coronary angiography to diagnose heart problems in heart attack victims. Using criteria for selecting elderly heart attack patients most in need of this diagnostic procedure (in which a catheter is threaded into the heart to inject a contrast dye to image the heart) apparently results in better outcomes for these patients, according to a recent study that was supported by the Agency for Healthcare Research and Quality (HS08071). Among patients who met appropriateness criteria for angiography, those who received it had significantly increased survival 1, 2, and 3 years later compared with those who did not undergo the procedure.

This survival benefit was probably due to the revascularization (coronary artery bypass surgery or angioplasty) or drug therapy initiated based on the results of the angiography, according to the researchers who are from Harvard University's Medical School and School of Public Health, Boston University School of Medicine, and Brigham and Women's Hospital. They compared the survival of 9,784 catheterized and 9,784 noncatheterized elderly Medicare patients hospitalized for heart attack (acute myocardial infarction, AMI) during 1994-1995 in one of seven States, who would have been recommended for angiography based on current criteria. Criteria include duration of symptom onset, patient age, prior use of thrombolytic (clot-busting) therapy, and presence of a condition complicating the heart attack (for example, shock, persistent chest pain, and/or recurrent irregular heartbeat).

Using information from medical record data, angiography was judged necessary for 29 percent of patients and appropriate for 34 percent; 36 percent of patients were judged to be uncertain candidates for angiography. By 3 years, the survival rate among necessary patients who underwent angiography was 73 percent compared with 56 percent among necessary patients who did not receive the procedure. In contrast, the survival rates were 83 percent and 75 percent, respectively, among catheterized and noncatheterized patients who were judged to be uncertain candidates. Patients who needed and underwent angiography were more likely to undergo revascularization within 3 months of the AMI and to be taking aspirin.

See "Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: A matched analysis using propensity scores," by Sharon-Lise T. Normand, Ph.D., Mary Beth Landrum, Ph.D., Edward Guadagnoli, Ph.D., and others, in the April 2001 Journal of Clinical Epidemiology 54, pp. 387-398.

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