HEART TREATMENT DEALT BLOW : STUDY REBUTS VIGOROUS APPROACH TO MILD CORONARIES.

Byline: Daniel Q. Haney Associated Press 

Aggressively treating mild heart attacks with angioplasty and bypass surgery, as is now common, may do more harm than good.

A major new study found the death rate is actually higher when patients with these less severe heart attacks are routinely examined with tubes pushed into their hearts - an exceedingly common technique that is standard practice at many hospitals.

The results challenge the widely held belief among cardiologists that fast, all-out treatment is best for all victims of heart attacks - even those who have relatively mild ones.

The findings surprised even the researchers who conducted the study. They are so at odds with accepted practice that they said many doctors are likely to be skeptical.

When the study began, the researchers speculated that a conservative approach would turn out to be as good as more high-tech treatments for these patients. But they didn't expected it to be decidedly better.

``We were just astonished'' to find that people who got the more aggressive therapy had a significantly higher death rate,'' said William E. Boden, who directed the study at the Veterans Affairs Upstate Health Care System in Syracuse, N.Y.

Boden presented the results last week at a meeting of the American College of Cardiology.

The study was conducted on 920 patients, mostly men, who had suffered what doctors refer to as non-Q-wave infarctions. These are relatively mild heart attacks, so called because of the way they look on electrocardiograms. They make up half of the 1.5 million heart attacks suffered in the United States annually.

In the aggressive approach tested in this study, doctors routinely send all of these heart attack patients to have catherizations. This is a test in which a tube releases dye into the heart arteries so X-ray movies can check the blood flow.

When significant narrowing is seen, the patients are given balloon angioplasty or bypass surgery to clear the blockages.

This aggressive strategy became routine in 1987 after the American Heart Association and the college of cardiology issued guidelines recommending it for non-Q-wave heart attacks.

However, the Veterans Affairs study is the first large attempt to see whether this kind of care really makes sense for mild heart attacks.

In the conservative approach, patients are monitored closely with so-called noninvasive tests, such as treadmill stress tests. They get angioplasty or surgery only if symptoms or tests suggest they are necessary.

After 2-1/2 years of follow-up, there were 34 percent more deaths and heart attacks in the aggressively treated group than among those getting conservative care.

The difference was apparent almost immediately. When discharged from the hospital an average of nine days after their heart attacks, 21 of the patients in the aggressive group were already dead, compared with six of those treated conservatively.

``I hope physicians will rethink their management approach to patients like this,'' said Boden.

Dr. Robert J. Cody of Ohio State University said doctors have felt compelled by the consensus of opinion that they should treat aggressively.

``This shows that in non-Q-wave infarctions, they don't have to be compelled,'' he said. ``They can use their clinical judgment.''

Some believe quickly pushing tubes into the heart after a heart attack may be dangerous because the injured arteries are vulnerable to further damage from the intrusion.

``Perhaps by delaying the intervention, we will have a better outcome,'' said Dr. Thomas Ryan of Boston University.