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 attackthat triggered by a
blood clot that blocks blood flow in a coronary artery. Many
also show a specific electrocardiographic pattern known as an
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 complicationssuch as blood
vessel perforation and other arterial injuries, which could trigger
another heart attackcan 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
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 angioplastya 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
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.