Heart Attack Care: Your life may depend on which hospital you choose

Big news was released today in the treatment of heart attack.

Please allow me a (slightly) wordy intro.

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I’m not normally an alarmist. I often vouch for the heart’s durability.

The exception to this rule is heart attack.

Heart attacks are…well…very serious. In this case, alarm is clearly a good thing. So is teamwork.

It’s been said so many times: Practicing medicine is a team sport. For without nifty tools and the help of trained staff, doctors would be useless. And few therapies show off the merits of teamwork more than rescuing patients from a heart attack (or MI-myocardial infarction.) It’s like a symphony—from paramedics doing ECGs in the field, to the wireless transmission of the ECG recording, a rapid transfer to an intervention-ready hospital, with a waiting and able cath lab staff and of course, the skilled interventional cardiologist who passes the wire, squishes the stent and takes the credit. All this triumph saves lives—of mothers and fathers and brothers and teachers and cycling buds, and on and on.

Yes, for sure, saving the life of another human is the highest reward. But I have to admit there’s also something else really enjoyable about the care of an acute MI. That is…the fact that it is a true emergency. So urgent is the need for timely intervention, medical people actually bypass nonsense—like box checking and stupid intake questions. Care comes first; documentation and chart reconciliation is an after-thought! (I don’t wish heart problems on anyone, but let it be said that watching my hospital’s team care for an MI is inspiring. It’s the fury of Medicine at its finest. Nonsense rides in the back seat. Teamwork and cooperation in the front.)

Okay, sorry about the wordy intro.

Let’s get to the news. As published in the journal, Circulation, (and nicely recapped by Reed Miller on theHeart.org) a group of researchers from North Carolina were able to show leadership and organization improved heart attack care across an entire state. This is amazing stuff.

The Study:

The outcome of a heart attack turns on the speed with which a closed artery is opened. (A medical term is necessary here—we call this emergency PCI or percutaneous coronary intervention, usually done with a stent.) The challenge is getting heart attack patients diagnosed and treated quickly. It’s easy when patients present to PCI-ready hospitals. In these best cases, the well-drilled teams spring into action and the patient gets whooshed to the cath lab for heart-saving PCI.

But this isn’t always how it happens in the real world. Many patients with heart attack are seen first in the field by EMS, or, they may present to hospitals not equipped for PCI. There they are; chest pain ongoing, heart muscle dying and life hangs in the balance. Seriously, we only have one heart.

The decision of where to treat a heart attack makes a huge difference. Time is muscle. Remember…it’s a true emergency.

This is where the efforts in North Carolina shine. Researchers were actually able to organize a statewide system—called RACE-Regional Approach to Cardiovascular Emergencies—that expanded rapid heart attack care to all hospitals in the state. Their methods were simple yet remarkable: (It all hinged on a pit-crew analogy–“where everyone knows what to do instead of trying to figure out who will do what.”)

• First, a leadership team was organized.
• Next, a registry that collected important data was initiated.
• Then came an agreement of 21 PCI hospitals in which all agreed to cooperate towards the single purpose of rapidly treating heart attack patients. Time is muscle—and heart muscle is life. They cooperated!
• The 98 non-PCI centers got on board to move quickly—either to transfer patients efficiently or to deliver clot-busting drugs. Again, they cooperated!
• The final step was communication between hospitals and EMS regarding all aspects of the process. This important step cannot be underestimated. It’s extraordinary to get competing medical systems to talk to each other. Cooperation!

Is it any wonder that a methodology that centered upon leadership, organization and a shared vision of the greater good for the patient resulted in favorable outcomes? Of course it did. This important study showed:

• More patients had attempts at opening the occluded artery.
• Treatment times for hospital transfer patients improved substantially.
• Patients presenting to non-PCI hospitals had shorter times to transfer and to intervention.
• Patients presenting to PCI hospitals received faster PCI.
• Most importantly, heart attack patients treated within time guideline goals had a mortality of only 2.2% versus 5.7% for those treated outside of guidelines.

The conclusions were easily supported by the data:

By extending regional coordination to an entire state, rapid diagnosis and treatment of [heart attack] has become an established standard of care independent of health care setting or geographic location.

My take home:

First, the researchers deserve a hearty shout out. This is incredible work. It’s hard to put into words how hard it is to overcome the bureaucracy of entrenched healthcare systems. I am stunned.

Second, this study reinforces an important public service message: Patients having chest pain and symptoms of heart attack should seek medical attention quickly.

Third, despite what billboards say about fast emergency care close to home, in the event of a heart attack, you are best served by going to a PCI-capable hospital. My hospital boasts some of the fastest PCI times in the state, but not infrequently, unsuspecting heart patients often go to two non-PCI hospitals across the street, where they experience delays in care. If a choice is feasible, always get to the PCI-ready hospital.

Finally, let’s end with a message of hope. Here is to hoping hospitals in the community can get past competitive forces to direct heart patients to the closest PCI-ready hospital. For if one thing is a certain in America; there’s plenty of heart disease treatment to go around.

Please folks. Be informed. In the event of chest pain and heart attack, you want care at a PCI-capable hospital. You want speed, teamwork and cooperation.

JMM