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Save the World

Saving the World from Heart Attacks

Heart attacks are the number one killer in the land.

A heart attack means the blood supply to the heart muscle has been cut off by a blood clot. The goal of treatment for people with heart attacks is to restore blood flow to the heart. 

This is called reperfusion therapy. It can be accomplished with angioplasty (inserting a very thin tube into the blocked artery) to remove the clot, or by giving the patient a  clot-busting medication. 

Angioplasty is the preferred reperfusion strategy. Clot-busting drugs take too long to work. 

The sooner angioplasty is done, the more heart muscle can be saved, and the greater the chances of surviving the heart attack. 

This is the basis of the mantra, time is muscle. 

Accomplishing prompt reperfusion has evolved over the past 30 years in three phases.

The first phase was the development of heart attack centers at hospitals, capable of providing the gold standard of care 24 hours a day, seven days a week. 

At first, efforts to reduce treatment times at these centers focused on getting the patient from the emergency department door to the cath lab as soon as possible so that an angioplasty can be performed promptly. This is called the door-to-balloon time (D2B). Today, the standard of care for D2B time is less than 90 minutes. Many studies have shown a strong association between prompt D2B and reduced risk of death. 

Based on this data, clinical practice guidelines of the ACC–AHA endorse a door-to-balloon time of 90 minutes or less as the goal, giving it a Class I (highest level) recommendation. This has led to a national focus on D2B. The Centers for Medicare and Medicaid Services and the Joint Commission began using door-to-balloon time as a performance measure for public reporting in 2002 and linking them to financial reimbursement. The ACC and the AHA developed national campaigns promoting strategies to improve door-to-balloon times through the creation of the D2B Alliance and Mission: Lifeline.

 The result of this is that over the past 10 years, times have improved to the point where D2B is less than 90 minutes almost 90 percent of the time. 

However, a 2013 study in the New England Journal of Medicine reports:

In conclusion, this study shows that between 2005 and 2009, there was a significant decline in national door-to-balloon times along with a steadily increasing percentage of patients meeting the guideline recommendation of a door-to- balloon time of 90 minutes or less for those presenting with an ST-segment elevation myocardial infarction. Despite these improvements, in-hospital and short-term mortality remained virtually unaffected. 

Our data suggest that further efforts to reduce door-to-balloon time may not reduce mortality. We therefore conclude that additional factors will probably need to be targeted to accomplish this goal. 

Therefore, efforts with potential to improve outcomes may include increasing patients’ awareness of symptoms, reducing the interval from the time of symptom onset to treatment, and shortening the transfer time between medical facilities. In addition, improving both in-hospital care and post discharge care remain key targets for enhancing long- term outcomes after ST-segment elevation myocardial infarction.

The second phase was to develop a prompt, reliable EMS system that could be accessed by calling 911. Highly trained emergency medical personnel arrive promptly at the scene, If they diagnose a heart attack, they call in to the cath lab to get the staff there ready. They then stabilize the patient and transport him or her directly to the heart center. They bypass closer hospitals, because those hospitals can’t provide the same level of care. 

  Once heart attacks centers and the EMS system were working well together, first medical contact to balloon time then became the time interval of importance. The recommendation from the latest ACC–AHA guidelines is still less 90 minutes, but now it’s from first medical contact (arrival of EMS at the patient) to balloon time

Many studies have shown a huge benefit in outcomes with an organized dedicated EMS transport system. Today, many major heart attack networks are able to achieve transport times of 20 minutes or less. Further improvements in phases one and two have not been found to lower mortality—this part of the system is working very well. 

There’s still a problem, however. Too many patients don’t recognize the symptoms of a heart attack and wait too long to call for help. By the time they are treated, even if that part happens very fast, the heart muscle has been damaged. We can’t always save these patients.

 Phase 3 now focuses on improving the time from the onset of symptoms to balloon time—the total ischemic time. Heart specialists now think this may be even more important than door-to-balloon time and first medical contact to balloon time.

An editorial in the same issue of the New England Journal of Medicine stated,

The primary opportunity for reducing total ischemic time and time to treatment, and for improving outcomes, now lies in the prehospital STEMI system of care, where logistic challenges remain. Most difficult to achieve has been a reduction in the delay from symptom onset to first medical contact.

Although it is shorter than it was several years ago, mean symptom duration is still 2 hours before first medical contact, and 40% of patients do not contact EMS. 

Continued efforts are needed to educate patients about STEMI symptoms and about calling 911 to permit EMS triage, treatment, and transport, as STEMI teams shift their focus from in-hospital to prehospital treatment delays. Although door- to-balloon time remains important, it’s time to turn our attention to the further development of systems that address the continuum of STEMI care, from symptom onset through return to the community.

The bottom line: Call 911 right away if you want to live!