Features April 2018 Issue

Faster, Better-Coordinated Care Is Improving Heart-Attack Survival

Big changes in the way heart-attack patients are treated in the ambulance and at the hospital are allowing more patients to survive “the big one.”

In a heart attack, minutes count. The faster blood flow is restored to the heart, the better the chance the patient will survive. Now, Cleveland Clinic and other major medical centers nationwide are working with emergency medical services (EMS) to make innovative changes in the way heart attack patients are treated. The result is faster heart-attack care and more patients leaving the hospital alive.

“With this new system, we have seen a 50 percent drop in the number of patients who die in the hospital after a heart attack,” says Umesh N. Khot, MD, Chief Quality Officer for Cleveland Clinic’s Miller Family Heart & Vascular Institute.

Beating the Clock

A heart attack occurs when a blood clot shuts off blood flow through an artery on the surface of the heart muscle. When this happens, the area of heart muscle nourished by this artery is starved of oxygen. Unless blood flow is restored in a timely manner, muscle tissue will die.

Some patients are left with a weakened heart that develops heart failure. Other times, when a significant portion of the heart is affected, the patient cannot survive.

The standard treatment for a heart attack is to restore the flow of oxygenated blood by opening the blocked artery with a balloon-tipped catheter. The American College of Cardiology recommends this be completed within 90 minutes of the patient’s arrival at the hospital—a measure known as “door-to-balloon” time. After 90 minutes, the likelihood the heart will recover drops significantly.

Restoring blood flow well before the 90-minute mark diminishes the likelihood the heart will suffer permanent damage. That’s why researchers have concentrated on finding ways to open the artery more quickly.

Slashing Door-to-Balloon Time

In 2014, Cleveland Clinic made substantial changes in the way heart-attack patients were treated by eliminating unnecessary steps in the process.

ambulance

© simonkr | Getty Images

If you experience the symptoms of heart attack, call 911 immediately. EMS can start treating you in the ambulance, and this may determine whether or not you survive the heart attack.

“We made sure an emergency physician could activate the cath lab instead of waiting for a cardiologist, and that it was ready to receive a patient at any time of the day or night. We also instituted a checklist to make sure nothing would be overlooked and all patients would receive the ideal treatment,” he says.

Two medical teams are on standby 24/7 to prepare heart-attack patients for catheterization. This saves valuable time on nights and weekends, while the cardiologist is en route to the hospital from home.

When a patient with heart-attack symptoms arrives in the emergency department, a cardiology fellow (cardiology resident with advanced training) confirms or rules out heart attack within 10 minutes.

An emergency department physician may page the standby heart-attack team to the cath lab.

cath lab

Image courtesy of Cleveland Clinic

Bypassing the emergency department and taking a heart attack patient straight to the cardiac cath lab for treatment restores blood flow to the heart faster, lessening permanent damage to the heart and saving lives.

In cases when an ECG taken in the ambulance verifies the patient is having a heart attack, EMS may bypass the emergency department and take the patient straight to the cath lab.

These new protocols have been extraordinarily successful. Since the program began in 2014, nearly 100 percent of heart-attack patients at Cleveland Clinic’s main hospital underwent angioplasty within the recommended 90 minutes. The average was 53 minutes: 40 percent were treated in less than 45 minutes, and many in as little as 21-22 minutes.

Changes Rolling Out Nationwide

Cleveland Clinic is not the only major medical center striving to improve heart-attack care. Hospitals nationwide are working closely with their regional EMS providers to improve door-to-balloon times in their own areas.

At the American Heart Association 2017 Scientific Sessions, physicians presented a study called ACCELERATOR-2, which mobilized 971 EMS agencies and 139 hospitals in 12 cities to coordinate heart-attack care. The study looked at the outcomes of 10,730 heart-attack patients, 6,695 of whom were taken to these hospitals by EMS providers trained to identify a heart attack on ECG and authorized to contact the cath lab directly.

In the first three months, the number of patients for whom the cath lab was activated within 20 minutes of calling 911 grew from 28 percent to 56 percent. Of those who were taken to the emergency department, the percentage that spent less than 20 minutes there grew by 10 percent. Nationally, more patients were treated within the 90-minute window in nine of the 12 participating cities.

Most importantly, in-hospital deaths among heart-attack patients dropped from 4.4 percent to 2.3 percent, and the rate of heart failure—the legacy of permanent damage from heart attack—dropped from 7.4 percent to 5 percent. The mortality rate in hospitals that were able to open the arteries within 20 minutes was only 2.2 percent.

emergency

© Alexmillos | Dreamstime

Improvements Continue

The changes made at Cleveland Clinic illustrate what can be accomplished within a single hospital or hospital system. ACCELERATOR-2 showed what can be done in a city or region—an enormous task involving multiple EMS agencies, independent hospitals, hospital systems and physician practices.

The good news is that as these improvements are adopted and refined by hospitals across the country, the chance of surviving a heart attack with minimal damage to the heart will improve exponentially.

“To date, the end result of all these changes is that many patients who would normally die from their heart attack will not only live, but will be able to go home and live a normal life,” says Dr. Khot.

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