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Coronary Heart Disease


Your Heart Attack Survival Plan

Calling 911 is the most important step anyone can take in the event of a heart attack. The standard emergency medical service (EMS) response is to take the patient to the nearest hospital so that lifesaving treatment can be started quickly. In most instances, the destination is one of the nation's 5,000 community hospitals, where thrombolytic therapy is administered.

Since thrombolytic therapy became available in 1986, it has saved the lives of countless patients stricken with the most common type of heart attack—that triggered by a blood clot that blocks blood flow in a coronary artery. Many also show a specific electrocardiographic pattern known as an ST elevation.

However, the common protocol of administering thrombolytic therapy first is now subject to revision based on the results of a recent multicenter trial published in the Journal of the American Medical Association (JAMA).

Two lifesaving treatments

Thrombolytic therapy employs medications known as tissue-type plasminogen activators (tPAs), such as tenecteplase and streptokinase, to dissolve the clot. These medications have revolutionized emergency medicine because they can be administered safely and promptly at any hospital. Once the patient is stable, he or she is usually transferred to another hospital, generally a larger or more specialized medical center, for angioplasty.

Angioplasty is a relatively noninvasive procedure that involves widening a narrowed artery by pressing back plaques with a balloon-tipped catheter. It generally restores blood flow better and for a longer time than thrombolytic therapy. A small, stainless steel wire mesh tube (known as a stent) is often permanently inserted into the artery to help keep it open.

When available, angioplasty can and should be used as initial emergency treatment (primary angioplasty) for most heart attacks in lieu of clot-dissolving medication. However, the procedure is restricted to hospitals where cardiac surgery is performed so that serious complications—such as blood vessel perforation and other arterial injuries, which could trigger another heart attack—can be corrected in the unlikely event they should occur.

Consequently, most patients receive thrombolytic therapy first, followed by angioplasty within a few days. Even at hospitals with cardiac surgery units, patients often receive thrombolytic therapy first because the equipment and staff needed for primary angioplasty are not always available.

A wider role for local hospitals

The JAMA study that may prompt revision of the current protocol examined the effectiveness of primary angioplasty when performed in community hospitals. It involved 11 such institutions in Massachusetts and Maryland. All implemented a state-of-the-art angioplasty program that included rigorous staff training, careful coordination among participating departments, and quality-control procedures. After these measures were adopted, 451 heart attack patients with documented ST elevations were randomly assigned to receive angioplasty (within 90 minutes of arrival) or thrombolytic therapy (within 30 minutes of arrival).

After six months of follow-up, patients in the angioplasty group fared better on all measures: The death rate was 6.2%, compared with 7.1% for tPA; the rate of recurrent heart attacks was 5.3%, compared with 10.6% for tPA; and the stroke rate was 2.2%, compared with 4% for tPA. Length of time in the hospital also was shorter for the angioplasty group: 4.5 days compared with 6 days for those who received tPA. Although these differences may seem small, they represent significant improvements in outcome.


The JAMA study, led by Johns Hopkins cardiologist Thomas Aversano, M.D., is the twenty-first consecutive trial to show the superiority of primary angioplasty over thrombolytic therapy for most heart attacks whenever practical. It shows that the procedure can be beneficial when performed at community hospitals, provided these institutions undergo an extensive angioplasty development program and adopt a state-of-the-art protocol.

"Given the superiority of primary angioplasty over thrombolytic therapy, it is important that health care policy be amended to provide the greatest number of patients access to this better form of therapy," Dr. Aversano says. "It should not be a matter of chance or geography that determines what kind of care a heart attack patient receives."

An editorial accompanying the study advised that, when possible, emergency protocols should be revised to increase the likelihood that patients experiencing acute heart attacks will receive primary angioplasty—a change that could be accomplished by establishing a system of specialized cardiac centers similar to the highly successful trauma center system.

Based on this model, EMS personnel would routinely take heart attack patients to specially designated hospitals that might be a mixture of institutions with and without on-site cardiac surgery. Community hospitals that participate would be required to implement an intensive angioplasty development program comparable to those at hospitals with cardiac surgery units.

Meanwhile, if a heart attack is associated with an ST elevation, opt for angioplasty as initial treatment if it is available. If primary angioplasty is unavailable, thrombolytic therapy is lifesaving and can be followed by angioplasty when appropriate.


911 Plus Aspirin

Regardless of your destination hospital or the initial emergency treatment you will receive, your response to the symptoms of a heart attack (chest pain with or without nausea, shortness of breath, vomiting, profuse sweating, breathlessness, faintness, weakness, or intense feelings of dread) should be the same: Call 911 immediately. The sooner treatment starts, the more effective it will be. Moreover, patients who are brought to the hospital by EMS personnel tend to receive attention more quickly than those who arrive on their own. If possible, while waiting for the ambulance, chew an aspirin to help dissolve the blood clot that may have triggered the attack


From The Johns Hopkins Medical Letter: Health After 50, August 2002.



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