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The use of angioplasty in the treatment
of heart attack (acute myocardial infarction) was first
done in the early
1980's. This treatment for heart attacks was very controversial.
The idea of bringing a patient who was in the midst of a
heart
attack
into the catheterization laboratory and performing a balloon
angioplasty seemed too risky. However, the instantaneous
opening
of the blocked coronary artery had the effect of halting
the infarction and restoring blood flow, thereby minimizing
the
damage to the heart muscle.
Interventional therapy, now usually
consisting of a balloon and stent, has progressed to the point
where it is currently considered the standard of care for
patients presenting with Acute Myocardial Infarction.
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controversy has also existed over the question of how to treat
heart attack patients in hospitals that have catheterization
laboratories (where angioplasty and other catheter-based interventions
can be performed) but do not have a cardiac surgery capability,
used as a back-up where a complication (collapsed or torn
coronary
artery, etc.) could be surgically repaired. As stenting became
more and more widespread, the safety of angioplasty increased
(see
recent study). In the late 90's, medical
personnel began discussing the feasibility of performing
angioplasty
on an emergency basis in hospitals without surgical backup
(see our Forum
topic that started in 1997 to trace this trend).
The largest study of its kind on this subject
was presented at the 2002 Scientific Sessions of the American
Heart Association -- the conclusion: emergency
angioplasty in hospitals without surgical backup is safe. More
recent studies, such as the DANAMI-2,
have strongly concluded that angioplasty is superior to
thrombolytic therapy (by
60%) even if the extra time involved in tranferring to
an angioplasty-capable center is up to two hours. |
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Nonetheless, speed to treatment
(door-to-balloon-time) is still critical, as demonstrated by
this graph, based on data from a June 2005 study in the American
Journal of Cardiology. This study confirms the
fact that that longer the delay
in
treating
STEMI (ST elevated
myocardial infarction) patients with angioplasty / stenting,
the worse the outcome. One-year
mortality increased from 3.2% to 12.1% as the time delay due
to interhospital transfer increased from less than 30 minutes
to greater than 90 minutes. Moral of the story: these times
need to be reduced. Patients with treatable MI should try to
get to a hospital that can perform angioplasty. |
Angioplasty is not available
at all emergency care facilities, but there are other effective
therapies, such as the administration of clot-dissolving drugs (see
American Heart Association recommendations on heart attack treatments).
Following are a series
of links to news articles and studies about this subject:
The
best treatment most heart victims aren't getting; Drugs more likely
to be used over angioplasty procedure
(October 10, 2003) A very interesting article
on why in many places heart attack patients are not being offered
angioplasty.
In the article, Dr. Joseph Carrozza, chief of interventional
cardiology at Boston's Beth Israel Deaconess Medical Center, states: "There
are a lot of strong community hospitals that aren't offering primary angioplasty
and would line up all their politicians against an effort to have heart attacks
taken away from their hospitals."
(source: CNN)
Time
essential for angioplasty U-M study says procedure still preferable
to clot-busting drugs but must be done quickly
(October
1, 2003) Adding to the controversy over how best
to treat heart attacks, this article reports on a study by the
University of Michigan that angioplasty needs to be
done within an hour to have an effect more beneficial than clot-busting drugs.
(source: Jo Mathis, Ann Arbor News)
A
Comparison of Coronary Angioplasty with Fibrinolytic Therapy in
Acute Myocardial Infarction
(August 21, 2003) Results of the DANAMI-2 study, published in today's NEJM, concludes
that transferring patients who are experiencing myocardial infarction with ST-segment
elevation
(heart attack) to a hospital equipped to perform angioplasty is superior to on-site
thrombolytic treatment, provided the transfer can occur within two hours. The
risk of death, repeat heart attack or stroke was reduced by 60%. This study strongly
bolsters earlier findings that heart attack patients should be brought to an
interventional center, NOT to the nearest hospital.
(source: New England Journal of Medicine)
Treatment
After Heart Attack Should Be Speedy
(August 6, 2003) A study headed by Dr. David A. Alter, from the University of
Toronto, published
in the current Journal of the American College of Cardiology (read
abstract here) states that heart attack patients
admitted to
hospitals that perform "invasive" treatments (angioplasty and bypass
surgery) do better than those at "non-invasive" hospitals.
(source: Journal of the American College of Cardiology / Reuters Health)
Decisions elsewhere may help area hospitals
(April 13, 2003) An article from Polk County, Florida, about the
effect that a Rhode island panel's recommendations regarding emergency
angioplasty without surgical backup will have on their local healthcare.
(source: Steven N. Levine, Polkonline.com)
Playing
Ambulance Roulette
(December 3, 2002) A dramatic article about the use of emergency
angioplasty, rather than thombolytic therapy, to treat heart attacks
-- "Death rates after 30 days are lower by almost 50 percent.
Also, angioplasty results in an open coronary artery 90 percent
of the time, compared with 54 percent for thrombolytic drugs."
(The New York Times requires readers to register, but it's free.)
(source: Sandeep Jauhar, MD and Norma Keller, MD, New York Times)
Emergency
angioplasty OK without surgical back-up
(November 17, 2002) Survival rates following emergency angioplasty
for heart attack are the same regardless of the availability of
on-site cardiac surgery, according to research reported today at
the American Heart Association's Scientific Sessions 2002. "This
is the largest study to date demonstrating the benefit of immediate
angioplasty in acute heart attack patients," says lead researcher
Timothy A. Sanborn, M.D., chief of the division of cardiology at
Evanston Northwestern Healthcare, in Evanston, Ill.
(source: American Heart Association)
Clot-Busting
Drugs Save Heart Attack Victims; Study finds early therapy effective
when time is important
(September 12, 2002) A French study shows results that contradict
the recommended standard of care in the U.S. -- that primary angioplasty
is superior to clot-dissolving drug. However, the results are not
as clear-cut as they could have been, due to low enrollment and
financing issues. In addition, 25 percent of the patients who got
clot-dissolving therapy ended up undergoing "rescue angioplasty" when
it was suspected the initial treatment had failed.
(source: ed Edelson, HealthScoutNews)
Late
Artery-clearing Procedure May Not Help
(September 9, 2002) A British study doubts the efficacy of performing
angioplasty 8 days or more after a heart attack to benefit the
patient.
But the study of 32 patients was questioned by Dr. Timothy Gardner
of the American Heart Association, who stated that such a delay
in post-MI angioplasty is not standard practice and noted that "there
is currently an ongoing trial sponsored by the National Institute
of Health that is looking at the efficacy of doing the artery opening
procedure within the first 12 to 24 hours after a having a heart
attack."
(source: Keith Mulvihill, Reuters Health)
Guidant's
MULTI-LINK Stents Demonstrate Benefit to Heart Attack Patients
(August 14, 2002) “The clinical data from the CADILLAC trial
demonstrates conclusively the benefit of stent implantation as an
immediate treatment for heart attack victims,” concluded principal
investigator Gregg W. Stone, M.D., Cardiovascular Research Foundation,
Lenox Hill Heart and Vascular Institute, New York. “For patients
presenting at centers skilled in angioplasty, stenting should now
be considered the new standard of care.”
(source: Guidant Corporation)
First
Patients Enrolled In Clinical Trial Of Guardwire Plus™ In
Patients With Acute Myocardial Infarction
(May 16, 2002) In a study intended to further demonstrate the
safety and effectiveness of balloon occlusion distal protection
during
vascular interventions, Medtronic, Inc., today announced the start
of its EMERALD (Enhanced Myocardial Efficacy and Recovery by Aspiration
of Liberalized Debris) trial. The study is specifically designed
to compare results in patients with acute myocardial infarction
(AMI), half of whom will be randomized to the new generation .028
inch GuardWire Plus™ Temporary Occlusion and Aspiration System,
while the other half will receive conventional percutaneous interventional
therapy (PCI) without embolic protection.
(source: Medtronic, Inc.)
A
Call for Change in Cardiac Care
(April 17, 2002) Today's front page New York Times article (registration
required) reports on an important meta-study of several randomized
trials. The study concludes that for patients suffering from acute
myocardial infarction (heart attack) angioplasty is the superior
treatment over thrombolytic therapy ("clot-buster" drugs),
even if the patient must be transported to a more distant hospital
where angioplasty can be performed in a catheterization lab. The
original study by Thomas Aversano, MD of Johns Hopkins and appearing
in today's issue of the Journal of the American Medical Association
(get
abstract here) states "...compared with
thrombolytic therapy, treatment of patients with primary PCI at
hospitals without on-site cardiac surgery is associated with better
clinical outcomes for 6 months after index MI and a shorter hospital
stay." "The implications of these trials are profound",
states Christopher P. Cannon, MD, of Brigham and Women's Hospital
and Harvard Medical School, in an
accompanying article, especially when one considers
that an estimated two-thirds of the more than one million Americans
who have heart attacks annually do not have access to angioplasty.
(source: Lawrence K. Altman, New York Times / Journal of the
American Medical Association)
Angioplasty
safe for the heartland
(April 16, 2002) A "popular press" report on the above
study. It states: "Numerous studies have shown angioplasty
is the best treatment for heart attacks. But some medical standards
and state regulations say doctors should perform angioplasties
only
at hospitals that have a cardiac surgery unit in case something
goes wrong. The new study challenges that thinking."
(source: MSNBC)
New Tack on Attacks
(April 4, 2002) When treating heart attacks, a new study from Denmark
(DANAMI II) suggests that angioplasty in the cath lab beats clot-busters
in the emergency room.
(source: ABC News)
Stents
Help Keep Blood Flowing After Heart Attack
(March 27, 2002) The CADILLAC trial results have been published
in the New England Journal of Medicine (read
abstract). The study, headed by Dr. Gregg W. Stone,
of the Cardiovascular Research Foundation at Lenox Hill Hospital
in New York, showed that heart attack (acute MI) patients who had
a stent implanted after undergoing balloon angioplasty were less
likely to have a heart artery re-blockage than patients treated
with angioplasty alone.
(source: Reuters / New England Journal of Medicine)
Many
Heart Attack Patients Miss Out on Treatment
(February 1, 2002) A new international study in The Lancet states
that 1 in 3 patients having a serious heart attack may not be given
emergency treatment to restore blood flow. These treatments are
normally "clot-busting" drugs or angioplasty. The patients
tended to be those over the age of 75, those without chest pain
and those with a history of diabetes, congestive heart failure,
heart attack or heart bypass surgery.
(source: Keith Mulvihill, Reuters Health / The Lancet)
Angioplasty.org
Forum Topic: Emergency PTCA without Surgical Backup
A very controversial topic in the area of emergency angioplasty
is the practice of PTCA (angioplasty) in hospitals that do not have
a surgical backup team, ready to perform emergency bypass surgery
if the angioplasty runs into trouble (see above article). The number
of emergency bypass surgeries performed has been radically reduced
since the implementation of the coronary stent, which has the ability
to hold the artery open. Still, there are complications which can
occur. Read postings from our FORUM from 1997 to the present regarding
this topic.
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See a video of Dr. Geoffrey Hartzler describing the 1st time
he used PTCA to treat a heart attack in 1980.