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Yale-New Haven Hospital
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New Haven, CT
06510-3202
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October 23, 2003
News this month More than a million Americans suffer heart attacks each year. Treating them with emergency angioplasty at major medical centers is a better alternative than administering clot-busting drugs at community hospitals even when a short transfer is required, according to a major study of heart attacks, published in the New England Journal of Medicine. Transfer to an angioplasty center improves a heart attack victim's chances of avoiding major complications by about 40 percent. Transfer… improves a heart attack
victim's chances of avoiding major complications by about 40 percent.
Currently most heart attack patients are treated only with clot-busting drug therapy, called fibrinolysis, even though research indicates they fare better when treated with angioplasty to clear the clogged blood vessel responsible for the heart attack. Many physicians believe angioplasty is appropriate, however, only for those patients who are seen initially at a medical center that offers emergency angioplasty. They are reluctant to delay treatment while patients are transported to another hospital. Study design Investigators analyzed the rate of complications, including death, another heart attack and disabling stroke occurring within one month of the initial heart attack. Results showed that 8.5 percent of those transferred for angioplasty versus 14.2 percent of those treated with fibrinolysis suffered a major complication. Rates were similar among those treated at one of the five hospitals offering angioplasty where 6.7 percent of those in the angioplasty groups suffered a complication compared to 12.3 percent of the fibrinolysis group. Angioplasty patients had fewer second
heart attacks.
The biggest benefit for angioplasty patients was fewer second heart attacks. Only 1.6 percent of these patients had a second heart attack, compared to 6.3 percent of those receiving clot-busting drugs. There was not a significant difference in the occurrence of death or stroke between the two groups. Can results be applied to the U.S.? Dr. Alice Jacobs, who performs angioplasties at Boston University Medical Center, said in an accompanying editorial, “…now is the time to discard the practice of transporting patients with acute myocardial infarction to the nearest hospital and to transport them preferentially to centers of excellence.” Others are not sure, including the lead author of the study, Dr. Henning Andersen, who said, “In my country, we don't have private hospitals. Everything is paid by the government. In the U.S., a hospital may be reluctant to transfer a patient because of the income from that patient.” Other physicians consider geography to be the major issue. Dr.
John Canto, who directs the coronary care unit at the University
of Alabama, said, “In Birmingham, we have 16 hospitals, and
12 can do that intervention, but if you are in rural Alabama, I
don't know whether the two hours you would have to drive would be
worth it.” 
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Efficient delivery care system essential This study demonstrates that if you are having a heart attack, you can do just as well if you are first taken to a community hospital and then transferred to a major medical center for angioplasty — if you can get there within a reasonable amount of time. And that's a big “if.” “Our goal … is to achieve
the balloon inflation phase of an angioplasty within 90 minutes
of the time a patient presents in the E.D.”
Time to treatment The study looked at transport times of up to two hours and found no significant differences in patient outcomes. Our goal at Yale-New Haven Heart Center is to achieve the balloon inflation phase of an angioplasty within 90 minutes of the time a patient presents in the emergency department (E.D.). We often are able to achieve this in less time depending on the time the patient arrives. When someone comes in with a heart attack, the cardiac catheterization lab is activated, which entails contacting the physicians and other health care professionals who form the cath lab team. In the middle of the night, it may take up to 45 minutes to get everyone in the lab, but often it can happen in less than 30 minutes. When a patient is being transported from another hospital, it should only take an additional 15 or 20 minutes provided the E.D. team at the referring hospital activates Yale-New Haven's cath lab immediately after assessing the patient. By the time the patient arrives by ambulance, the cath lab team is ready. We're currently working with others in the state to ensure the emergency transport system works as quickly and efficiently as possible. “Angioplasties have been shown
to result in better outcomes for patients.”
The angioplasty advantage What can you do? Time is of the essence in treating heart attacks, and our advice would be to call 9-1-1 immediately and ask to be taken to the closest hospital you believe delivers high quality care. We would also urge anyone with a history of heart disease or who is at high risk to develop and sustain an ongoing relationship with a physician who is trained to take care of patients with cardiovascular disease. That physician's knowledge of your medical history is an invaluable advantage to an emergency department. Are more angioplasty centers the answer? Study after study has shown that for complex specialized care, the more experience the health care team has, the better the results. According to a report published in the Annals of Internal Medicine (September 17, 2002), the majority of studies find a lower patient mortality rate for a given procedure when the hospital or physician has high-volume experience performing that procedure. A team that conducts 1,500 to 2,000 angioplasties a year as we do at Yale-New Haven is much more likely to do a better job than a smaller center that may perform 200. That doesn't mean that small hospitals don't deliver good care. They do; but when we look at large populations of patients, the percentages of good results favor experience. Expense is another consideration since training, equipping and
staffing a cardiac catheterization lab for emergency angioplasty
24/7 costs millions of dollars. Putting a small percentage of
those financial resources into upgrading the emergency transport
system might be a better investment. Getting patients to centers
where teams have extensive experience treating those having heart
attacks quickly and effectively offers patients the best chance
of a full recovery. Dr. Cabin is a professor of cardiology at the Yale School of Medicine and an attending cardiologist at the Yale-New Haven Heart Center. |
