Ethics in cardiovascular medicine. Task Force III: Perspective on the allocation of limited resources in cardiovascular medicine

An evaluation of potential prognostic indicators in cardiac patients

Cardiovascular disease results in more deaths and higher medical costs than any other medical problem. Cardiac patients may be transported to centers for specialized care. We evaluated historical, current event, and physiologic items (n = 32) for ability to predict use of specialized care and hospital costs. For 199 patients studied, seven items were prognostic. A model classifying patients by presence of predictors was developed. For the group without predictors and the group with multiple predictors, sensitivity and specificity were respectively very good. For 125 (63%) of the patients in middle categories, the model was not sufficiently sensitive to be prognostic. A scoring system for all cardiac patients could not be developed. Patients requiring only diagnostics were responsible for financial deficits, as were all Medicare patient groups. Patients staying longer than seven days, or having surgery, or both, were responsible for the largest deficits (if on Medicare) and the highest profits (if not on Medicare). Advance validation of the need to transport is difficult, with far-reaching medical and financial implications.

Management of coronary heart disease in the elderly

The prevalence of coronary heart disease (CHD) increases rapidly with advancing age and remains the major cause of death among elderly Americans. The number of elderly has doubled in the last 30 years and is projected to continue growing at more than twice the rate of the general population. The resources required in managing CHD in this population will reach astronomical levels during the next few decades and will severely tax our ability to provide adequate medical care to all citizens, unless cost effective diagnostic and therapeutic strategies are developed which do not severely compromise health care. Risk factors for CHD should be identified and modified as early in life as possible. Modification of risk factors begun at advanced age appears to confer benefit, however. Anti-ischemic drug therapy is the treatment of choice for patients with mild or moderate stable angina. Select elderly may be willing to accept the increased risks of coronary revascularization to achieve relief from debilitating angina or prolongation of life. Physicians must use care in planning diagnostic and therapeutic strategies. Quality of life and independence are often more important considerations than longevity in this age group.