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Emergency Angioplasty
System is a Life-Saver in Ottawa, Canada
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January 16, 2008 -- A reports in tomorrow's issue of the New England Journal of Medicine describes a protocol that reduced mortality in the emergency treatment of heart attacks in Canada's capital city of Ottawa during 2005-06. It is well-known that emergency angioplasty is the number one treatment for a heart attack, or myocardial infarction, which is caused by a sudden blockage in one of the major coronary arteries. The blockage is opened by a balloon and blood flow is restored, instantly stopping the heart attack in its tracks. Emergency angioplasty (also called PCI, for "Percutaneous Coronary Intervention") has been one of the miracles in the treatment of acute heart disease. Thirty years ago more than 1 in 4 heart attack victims died in the hospital. Today 95% survive. A heart attack is no longer a death sentence. The problem has been getting the patient to this treatment quickly enough: 90 minutes has been cited in a number of studies as the window within which angioplasty should be performed for optimal results. Studies have shown that for every 30 minute delay, one-year mortality is increased by 7.5%. Cardiologists are well aware that the challenges of getting the patient to treatment in time are many: the patient needs to be diagnosed quickly; there must available catheterization laboratories where emergency angioplasty can be done, either in the same hospital as the ER, or one nearby; the cath labs must operate on a 24-hour basis; hospital staff needs training to identify patients suffering a heart attack (myocardial infarction) and to transport them to a cath lab without giving them thrombolytic drugs (so-called "clot busters") which have been shown to not be as effective as primary PCI. In the United States, the American College of Cardiology created the "Door-to-Balloon Alliance" to address these issues -- specifically speeding up the time from "door", when the patient presents at the Emergency Room, to "balloon", when the angioplasty balloon is actually inflated in the blocked artery. However, in Ottawa, a unique protocol was established and many patients never went to an Emergency Room to be diagnosed and referred to an angioplasty center. Instead they were triaged by the Emergency Medical personnel right in the ambulance and brought directly to the cath lab of a high-volume PCI hospital. The results were significant: the median door-to-balloon time for those brought directly to a cath lab was 69 minutes. For those who had to be referred from an Emergency Department, the time was almost double: 123 minutes. At the end of 30 days, mortality for the patients who were taken directly to an angioplasty hospital was 4.4%; for those who were referred through an Emergency Department the mortality rate was 5.7%, or 30% higher. The results of this study, which involved 344 consecutive patients, should provide an impetus for urban centers everywhere to begin implementing training protocols to provide this life-saving treatment for all citizens. |
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