May 29, 2014
News Review From Harvard Medical School -- Study Shows Risk of Delaying Blood Thinners
Many people don't start taking prescribed blood thinners right away after getting a stent inserted in an artery near the heart. And those who delay are more likely to have heart attacks and die, a new study shows. Stents are tiny metal mesh tubes. They are placed inside narrowed arteries that are opened with balloon angioplasty. The stents help keep the arteries open. People need to take blood thinners for a month to a year after receiving a stent. This helps to prevent heart attacks during healing. Researchers looked at records for more than 15,600 people who had stents placed. About 30% did not fill their prescriptions for the blood thinner clopidogrel (Plavix or generics) within 3 days of hospital discharge. In the 30 days after discharge, they were 3 times as likely to have heart attacks as people who started taking the medicines right away. They were 5 times as likely to die in that month. In the next 2 years, this group also had double the rate of heart attacks or death as those who started blood thinners promptly. The Journal of the American Heart Association published the study. HealthDay News wrote about it May 28.
By Robert H. Shmerling, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
The development of heart stents has been a major advance in the treatment of heart disease. These tiny tubes are inserted into arteries around the heart to keep them open after removal of a blockage. By preventing heart attacks or limiting their size, stents are truly lifesavers.
However, soon after doctors began treating patients with stents a big problem surfaced. Studies found that stents can become blocked or "clotted off," leading to a heart attack. That's just the thing they were intended to prevent. This often happened in the first few days or weeks after stent placement. Blood thinners, such as aspirin and clopidogrel, can prevent this from happening. As a result, doctors routinely prescribe these drugs after they put in stents.
Of course, medicines don't work if you don't take them. And that's just what researchers found in a new study of people receiving coronary stents.
Among more than 15,000 people who recently received a stent, about one-third did not fill their prescriptions promptly. As a result, they spent at least a few days without the combination of drugs that was recommended.
There was a cost to this delay. Compared with those who promptly filled their prescriptions, those who didn't fill their prescriptions within 3 days had:
- Triple the risk of heart attack within 30 days
- 5 times the risk of death within 30 days
- Double the risk of heart attack or death within 2 years
The results were similar for both types of commonly used stents, drug eluting and bare metal. Drug-eluting stents release a drug to help prevent narrowing of the artery. Bare-metal stents don't do this.
Medical care today is often complex and hi-tech. But this study is a stark reminder that some simple measures, such as filling a prescription and taking a pill, can have a big impact. And it points out the challenge of getting people to take their medicines as prescribed.
What Changes Can I Make Now?
If you've had stents placed, the message of this study is clear: take your medicines exactly as they are prescribed. This is especially important just after a stent has been inserted.
It's important to know what type of stent you have. After the insertion of a drug-eluting stent, blood-thinning medicines (such as aspirin and clopidogrel) are recommended for at least 6 months. Ideally, they should be taken for 12 months. For bare-metal stents, the blood-thinner treatment should last at least a month.
There are many reasons people don't take their medicines as recommended. Two of the most common are side effects and cost. Even though side effects are common, they may not require you to stop taking the medicine. For example, your doctor may recommend a dose adjustment or a change in the time of day that you take the pills. Generic medicines and drug companies' patient-assistance programs are examples of ways to address the high costs of many medicines.
Regardless of the reason, if you are having difficulty taking your medicines as prescribed, let your doctor know.
All of us can also take steps to prevent or treat heart disease. They can reduce the chances you will ever need a stent or the medicines that must be taken with them. Here's what you can do to prevent heart disease:
- Keep your weight in an ideal range.
- Choose a healthy diet.
- Get regular exercise.
- Don't smoke.
- Keep your blood pressure and cholesterol in an ideal range.
Similar measures are recommended for people who already have heart disease. These steps can reduce the risk of heart attack, stroke and other problems.
What Can I Expect Looking to the Future?
I hope that studies like this one will encourage people to take their medicines as prescribed. However, it's likely that such research won't be enough. One option would be to provide medicines to patients before they go home from their stenting procedures. Another idea is to contact patients at home to make sure they are taking their medicines without difficulty. Smart phones and computers can be programmed to remind people to take their medicines.
Perhaps you have even better solutions. The important thing is that we make it easy for the right things to happen.