Features March 2013 Issue

New Heart Attack Treatment Guidelines Stress Rapid Response

The recommendations are aimed at treating patients with complete blockage of a coronary artery.

The American Heart Association (AHA) and the American College of Cardiology (ACC) have released new guidelines for the treatment of a serious type of heart attack known as ST-elevation myocardial infarction (STEMI). STEMI occurs when plaque in a coronary artery ruptures and a blood clot forms that completely blocks blood flow to the heart muscle. Damage to the heart begins quickly and can be quite severe.

Marty Bee

When plaque completely blocks blood flow in a coronary artery a type of heart attack known as a STEMI occurs, damaging a portion of the heart muscle near the blockage.

The new guidelines emphasize the need for quick decision-making, from the recognition of symptoms by the patient or those close to him, to the response of healthcare providers in returning healthy circulation to the heart.

Stephen Ellis, MD, section head of Invasive/Interventional Cardiology in Cleveland Clinic’s Robert and Suzanne Tomsich Department of Cardiovascular Medicine at the Sydell and Arnold Miller Family Heart & Vascular Institute, says that while the guidelines could still be made stronger, they represent a good update in the care of these vulnerable patients.

“The key to successful outcomes remains rapid restoration of blood flow while minimally exposing the patient to complications such as stroke,” Dr. Ellis says. “It is important to understand that most of the heart muscle damage with a heart attack occurs in the first few hours.”

Recognizing symptoms
Of course, the key to rapid and effective response to any type of heart attack is a recognition of symptoms and the decision to call 911. The AHA notes that patient delay in reporting symptoms is one of the greatest obstacles to successful care.

Leslie Cho, MD, section head, Preventive Cardiology and Rehabilitation in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at Cleveland Clinic, says the two most common symptoms are chest pain and shortness of breath, but there are other signs, too, such as pain in the back or jaw, and sudden nausea.

“Some patients have excessive fatigue,” Dr. Cho says. “If you are not feeling well, call your physician and let the professionals figure it out. We often see patients who show up to the hospital late because they did not want to bother someone or didn’t think their symptoms were cardiac. Let the professionals make that decision.”

The new guidelines specifically discourage travel by private car to an emergency room, and instead recommend a 911 call. Also, as part of the new recommendations, emergency medical technicians should perform electrocardiograms in the field to help facilitate rapid triage and speedier treatment.

Understanding PCI
The preferred treatment for someone having a STEMI is a procedure known as percutaneous coronary intervention (PCI), which uses a catheter to place a tiny balloon in the blocked artery to open it up and to leave a stent at that location to keep the artery open.

Dr. Cho says the recommended time for a patient to be have that balloon angioplasty is usually within 90 minutes from arrival at the ER. Patients who live far from hospitals or medical centers that do PCI often have to be transferred from a local ER to an appropriate facility. That transfer should take less than 30 minutes.

“Unfortunately, the national average for this time is over 60 minutes,” Dr. Ellis says. “This has led to a national discussion as to whether or not EM services should transport patients only to ‘PCI-accredited’ emergency rooms or hospitals.”

He adds that at first-rate centers, blood flow can often be re-established in 95 percent of the patients within 30 minutes after the patient arrives in the catheterization laboratory.

“The keys to post-STEMI care are aggressive management to reduce the risk of another heart attack and for the patient with a severely damaged heart to optimize their muscle recovery,” Dr. Ellis says.

Part of that care will include the use of aspirin and anticoagulants such as prasugrel or ticagrelor, as well as statins to reduce plaque buildup.

Dr. Cho emphasize the vital importance of faithfully adhering to your prescribed medication regimen and following up with appointments with your physician to monitor your recovery and your ongoing heart health.

“I can’t tell you how many patients stop taking medications and do not tell their doctors about it,” Dr. Cho. “It is crucial to keep in close contact with your physician after your heart attack.”

The other important aspect of post-STEMI care is cardiac rehabilitation, which should begin as soon as you are deemed ready for it by your doctor. Phase 1 of cardiac rehab takes place in the hospital after your procedure, and consists of patient and family education, a measure of your exercise ability, medication instruction and a determination of your ability to take care of yourself, including bathroom needs, dressing yourself, etc.

Phase 2 cardiac rehab is an outpatient program that emphasizes supervised exercise and further education about lifestyle changes, diet and medication.

“Remember, enrollment in cardiac rehab phase 2 saves lives,” Dr. Cho says. “Usually most insurance pays for cardiac rehabilitation phase 2 program where you exercise one hour a day, three times a week for 12 weeks.”