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Minutes Matter When You're Having a Heart Attack A Hospital Should Give You an Artery-Clearing Angioplasty Within 90 Minutes of Your Arrival, Yet Many Struggle to Do So

Posted on: Wednesday, 7 September 2005, 21:00 CDT

One day in April, Dennis Degroot, 53, came home a little early from his job in Lombard. He took the chance to rake some old leaves littering the driveway.

He felt sluggish, like he was walking in slow motion, but he chalked it up to the cortisone injections he'd received for a sore back. Then he felt a twinge in his chest.

Degroot took a shower to help him feel better. By the time he got out, his chest pain was so severe he dropped to his knees and had to roll across the floor to reach the phone to dial 911. Degroot was suffering a massive heart attack.

Degroot was lucky. The nearest hospital, Advocate Good Samaritan in Downers Grove, had been working to speed up treatment for heart- attack patients. Paramedics called ahead with his symptoms, and by the time the ambulance arrived doctors had assembled.

"Going through those double doors, I'll never forget how many people were lined up waiting for me," Degroot said. Forty-one minutes later, a cardiologist had threaded a balloon-tipped wire through Degroot's artery to clear the clot and inserted a tiny mesh tube to prop it open.

"With Mr. Degroot, it just worked the way it was supposed to," said Dr. Diane Wallis, a cardiologist with Midwest Heart Specialists who was on duty that afternoon.

Forty-one minutes is fast by anyone's measure. The American Heart Association recommends patients wait no longer than 90 minutes for an artery-clearing angioplasty, considered the best treatment for heart attacks in most cases. Older standards gave a two-hour window from the time a patient enters the emergency room.

Yet many hospitals struggle to erase stubborn minutes that clog the process.

In a national study of 68,000 patients published last month in the Journal of the American Medical Association, patients waited an average of 95 minutes during regular business hours for an angioplasty. After-hours patients waited an average of an hour and 56 minutes.

Less than half of patients were treated within the 90-minute guideline recommended by the American Heart Association, even during daytime hours.

Delays raised the risk that patients would die by about 7 percent.

Since two-thirds of heart-attack patients showed up on nights and weekends, the study suggests that hospitals must find better ways to more quickly bring after-hours staff into cardiac catheterization labs, where the angioplasties are performed, said study co-author Dr. Harlan Krumholz of Yale University School of Medicine.

"We need to ensure there are systems in place to get patients the best care possible, no matter when they show up," he said.

Cardiac alert

Three years ago, patients at Good Samaritan waited an average of 99 minutes for a balloon angioplasty. Doctors were surprised at the figures; a decade earlier, the hospital was averaging just 55 minutes door-to-balloon.

"We should be getting better, not worse. We tried to figure out what had changed," said Dr. Peter Kerwin, an interventional cardiologist at Good Samaritan. "Part of what we saw was the paramedics were more involved with that diagnosis."

In the early 1990s, Good Samaritan was researching clot-busting drugs. They set up a system so paramedics equipped with electrocardiograms could diagnose heart attacks in the field and administer life-saving medications. Just as that project began, however, the hospital launched an angioplasty program. The more effective surgical treatment quickly eclipsed drug therapy.

Since paramedics already had the equipment to detect heart attacks, they often called ahead to alert the hospital a patient was on the way. That 15-minute warning meant the hospital could assemble the specialists needed to diagnose a heart attack and staff the catheterization lab.

Good Samaritan went back to that system in 2003 and immediately shaved 20 minutes off its average time, Kerwin said.

As part of the new Cardiac Alert program, the hospital also made other adjustments, such as moving an electrocardiogram machine into the emergency department. Patients in the midst of a heart attack no longer have to travel to a different part of the hospital for the diagnostic test, saving five minutes.

They also started to call in specialists at the first clue a patient could be having a heart attack.

"If one person along the line thinks it's a heart attack, we trigger the system," Kerwin said. "If we find out down the line it's something else, we can deal with it. We can send the people home."

Kerwin estimates such "false alarms" occur 20 percent of the time. He wouldn't mind if it happened more often, if only to ensure the hospital caught as many actual heart attacks as possible.

The results have been positive; in the past six months, Good Samaritan has averaged 68 minutes door-to-balloon. On weekdays, the hospital averages 42 minutes. In off hours, when staff must be called in, the time goes up to 83 minutes.

The hospital's goal is to reduce its average time to less than 60 minutes, Kerwin said.

"Realistically, even for nighttime hours, a door-to-balloon time of 60 or 65 minutes should be attainable," he said. "That is what our goal is."

Eliminating delays

The JAMA study found patients are likelier to die of a heart attack if they arrive at the hospital at night or on a weekend, in part due to the delay in treatment.

Getting specialists into the hospital often constitutes the biggest delay, even when staff are required to live nearby. Few hospitals staff their cath labs around the clock.

"It's just cost-prohibitive," Wallis said.

So local hospitals are looking for other ways to speed the process.

Midwest Heart Specialists, a large practice of cardiologists based in DuPage County, plans to implement Cardiac Alert at other hospitals, including Advocate Good Shepherd Hospital in Barrington, Edward Hospital in Naperville and Elmhurst Hospital.

In Arlington Heights, Northwest Community Hospital launched its own Cardiac Alert program earlier this year. In the past three months, the hospital has shaved 14 minutes off its door-to-balloon time, which now averages 93 minutes.

"Our goal is to get it under 90 consistently," said Bonnie DeGrande, director of cardiovascular services.

Northwest Community works with paramedics who are equipped with 12-lead electrocardiograms. If they detect a heart attack in a patient, paramedics call the emergency department, where doctors announce a cardiac alert.

"That mobilizes a variety of resources," said Dr. Ronald Thomas, assistant medical director of the emergency department. "We open up a bed. We have an EKG ready. We have all the people waiting to do a chest X-ray, a nurse to establish an IV, and simultaneously we call the interventional cardiologist and the cath lab."

Ideally, the team is ready when the patient arrives. The hospital's record so far is 42 minutes door-to-balloon.

In Lake County, a number of rescue companies have added electrocardiograms to their ambulances in recent years.

"All of my fire departments have purchased the equipment," said Debbie Semenek, EMS system coordinator at Condell Medical Center in Libertyville.

Condell has not started tracking the data to see if patients are being treated more quickly as a result, Semenek said. Anecdotally, though, she cited cases where paramedics diagnosed a heart attack in the field during a night shift, giving ER doctors enough warning to call in the cath-lab staff.

That warning can save 30 minutes, said Dr. Timothy Alikakos, an interventional cardiologist at Condell.

"Even a half hour is very important," Alikakos said. "We do know that the earlier the patient gets in, whether it's an hour compared to two hours, there is a significant change in the percentage of muscle tissue that's already dead."

Quicker treatment results in lower mortality rates as well as a smaller chance the patient will have continuing problems, such as a weak heart, rhythm disorder or other issues, Alikakos said.

But challenges remain. In Illinois, only 44 percent of patients are treated within the 90-minute guideline, compared to 45 percent of patients nationwide, according to the National Registry of Myocardial Infarction.

Delays in treating patients on nights and weekends occurred in all types of hospitals, including those that do a high volume of angioplasties.

The record is better with clot-busting drugs, which can be administered in emergency rooms staffed 24 hours a day. In the JAMA study, daytime patients waited an average of 33 minutes for medication. After-hours, the wait increased just one minute. The American Heart Association recommends medications be given within 30 minutes of arrival.

Nationwide, the majority of heart-attack patients are treated with medication rather than angioplasty. In the Chicago area, most hospitals are equipped with catheterization labs, so balloon angioplasty has become the preferred treatment.

The bottom line is to get treatment fast.

"The major factor is simply the patient deciding he needs to come in," Alikakos said. "Many times we have patients waiting three, four, five hours, sometimes the whole day before they decide this is something real. The more aware patients come in within the first few minutes, and those are the patients who do themselves the most good."

- The Associated Press contributed to this report.

Source: Daily Herald; Arlington Heights, Ill.

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