A sea change in treating heart attacks
Yvette Samuels was listening to jazz late one night when she felt a stabbing pain down her left shoulder. She suspected a heart attack — she had heard about the symptoms from watching a Rosie O’Donnell standup routine on television — and managed to scratch on the door that connected her single room to her neighbor’s. He found her collapsed on the floor.
Paramedics arrived minutes later and slapped electrocardiogram leads on her chest, transmitting the telltale pattern of a heart attack to Our Lady of Lourdes Medical Center here.
As the ambulance raced through the streets, lights swirling, sirens screaming, Ms. Samuels, who took phone orders for a company that delivers milk, asked the paramedic, “Can this kill me?” He murmured yes, then told the driver, “Step on it!” She thought to herself, “This will be my last view of the world, the last time I will see the night sky.”
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Instead, she survived, her heart undamaged, the beneficiary of the changing face of heart attack care. With no new medical discoveries, no new technologies, no payment incentives — and little public notice — hospitals in recent years have slashed the time it takes to clear a blockage in a patient’s arteries and get blood flowing again to the heart.
The changes have been driven by a detailed analysis of the holdups in treating patients and a nationwide campaign led by the American College of Cardiology, a professional society for specialists in heart disease, and the American Heart Association. Hospitals across the country have adopted common-sense steps that include having paramedics transmit electrocardiogram readings directly from ambulances to emergency rooms and summoning medical teams with a single call that sets off all beepers at once.
From 2003 to 2013, the death rate from coronary heart disease fell about 38 %, according to the American Heart Association citing data from the Centers for Disease Control and Prevention. The National Heart, Lung and Blood Institute, the primary federal agency that funds heart research, says this decline has been spurred by better control of cholesterol and blood pressure, reduced smoking rates, improved medical treatments — and faster care of people in the throes of a heart attack.
“It may not be long before cardiovascular disease is no longer the leading cause of death” in the United States, said Dr. Michael Lauer, the director of the Division of Cardiovascular Sciences at the National Heart, Lung and Blood Institute.
WHAT IS A HEART ATTACK?
The heart has four chambers, which are separated by valves and surrounded by muscle.
The right side pumps blood back to the lungs for more oxygen.
The left side pumps oxygen-rich blood through the body.
Cardiac arteries supply oxygen-rich blood to the heart muscles.
If an artery becomes clogged or blocked, the downstream muscle is starved of blood.
This is a heart attack.
Sources: Dr. Reginald Blaber, Dr. Harlan M. Krumholz, Dr. Karthik Murugiah and Dr. Brahmajee K. Nallamothu
By Larry Buchanan, Jonathan Corum, Yuliya Parshina-Kottas and Graham Roberts
And care has improved not just in elite medical centers, but in local hospitals like Our Lady of Lourdes, here in a city littered with abandoned buildings and boarded-up homes that is among the poorest in America, according to the Census Bureau. Disparities that used to exist, with African-Americans, Hispanics and older people facing the slowest treatment times, have disappeared, Dr. Harlan Krumholz, a cardiologist at Yale, and his colleagues said in a paper in Archives of Internal Medicine.
The reinvention of protocols to hasten treatment is part of a broad rethinking of how to tackle coronary heart disease, which accounts for one of every seven deaths in the United States or 375,000 a year. Just this month, powerful drugs from the first new class of medicines to lower bad cholesterol levels in a generation neared approval by the Food and Drug Administration, raising hopes that they will further reduce the death rate from heart disease. At the same time, new, less invasive methods for replacing aged heart valves are raising hopes that ailing patients will be able to live longer. And researchers are immersed in resolving issues that remain unsettled: the utility of stents to treat the heart pain known as angina and the ideal level for blood pressure.
Lack of Speed Kills
In a heart attack, a blocked artery prevents blood from reaching an area of heart muscle. At first, cells are merely stunned, but as minutes tick by, they start to die. The way to save the heart is to open the blocked artery by pushing in a catheter, inflating a tiny balloon that shoves the blockage aside, and holding the artery open by inserting a stent, a tiny wire cage.
But leading cardiologists had despaired of reaching a national goal set by the American College of Cardiology and the American Heart Association of getting this done for at least half of heart attack patients within 90 minutes of arrival at a hospital. Often it took more than two hours for blood to flow to a patient’s heart again.
Procedures at Lourdes allow cardiologists like Dr. Thierry Momplaisir, right, and nurse Krista Damirgian to start working on a patient faster. Credit Mark Makela for The New York Times
Now, nearly all hospitals treat at least half their patients in 61 minutes or less, according to the most recent data from the American College of Cardiology. At Yale-New Haven Hospital, where half the patients used to have to wait at least 150 minutes before their arteries were opened, the median time is now 57 minutes. At the Mayo Clinic and at major academic centers like NewYork-Presbyterian Hospital, it is 50 minutes — a statistic that, amazingly, Lourdes matches.
Some cardiologists still express sadness at the price many patients paid when care was much slower. Dr. Mahesh Bikkina, the director of the cardiac catheterization laboratory at St. Joseph Regional Medical Center in Paterson, N.J., tells his trainees about the old days: heart muscles that tore, with blood leaking out of holes, and valves that ruptured, leading to sudden death if not repaired immediately with open-heart surgery.
“I tell them you will read about these things in textbooks,” Dr. Bikkina said. “You will almost never see them.”
Dr. Brahmajee Nallamothu, a University of Michigan cardiologist, said he remembered patients who became cardiac cripples after long delays in receiving treatment, their hearts so damaged that the slightest exertion exhausted them.
“What I feel about this, what is really meaningful to me, is when we finally stopped saying, ‘You know, this stuff happens,’ and started taking control and saying, ‘This is not acceptable,’ ” Dr. Nallamothu said.
The improvements in treatment have spilled over into the care of stroke victims. Neurologists watched with envy as cardiologists slashed their times. For strokes, too, the time it takes to be treated with the clot-dissolving drug tPA is of the essence. “Time is brain,” neurologists say. They began to copy the cardiologists.
“Seeing that someone else could do it was remarkably motivating and a little bit competitive,” said Dr. Lee H. Schwamm, the chief of stroke services at Massachusetts General Hospital. “If they can do it, why can’t we?”
The payoff from the changes has been breathtaking, experts say.
“Heart disease mortality is dropping like a stone. This is a reason why,” said Dr. Eric Peterson, a cardiology researcher at Duke. “And stroke has fallen to fifth as a major killer. This is a reason why.”
Source: NYT
