Angioplasty:
the "gold
standard" for treatment of
heart attack
April
17, 2010 -- "Lack of
health insurance and financial concerns about accessing care
among those with health insurance were each associated with delays
in seeking emergency care for AMI." That's the conclusion of
a study, published in Wednesday's Journal of
the American Medical Association (JAMA) and the implications
of this study for hospitals, insurance providers,
government and interventional cardiologists are
profound, because angioplasty and stents are considered the
first line
treatment
for a serious
heart
attack, yet many patients are not
benefiting from this treatment.
Angioplasty: The "Gold Standard"
Since balloon angioplasty was first used
in 1980 to treat acute myocardial infarction (AMI or heart attack)
numerous
published
studies
have
shown this procedure to be the "gold standard" -- opening
a blocked artery and instantly restoring blood flow and oxygen to
the heart muscle quite literally stops a heart attack in its tracks.
30 years ago one out of four patients who arrived
at a hospital in the midst of a heart attack died; today almost 99
out
of 100 survive
-- and for many of those patients who make it to the ER quickly,
the experience is relatively minimal: within 90 minutes of arriving
at
the hospital,
a balloon is inflated, a stent is placed, and the intense pain
disappears -- their heart muscle is not damaged,
allowing
them to
lead normal lives,
unencumbered by chronic heart failure, and they are usually back
home in three days or less.
Recognizing the importance of this concept that
"time is muscle", the American College of Cardiology launched the D2B
Alliance™ in 2006, enlisting hospital, other heart
organizations, government agencies and cardiologists in what has
been an extremely successful effort to ensure that heart attack
patients arriving at the Emergency
Department are diagnosed and transported to the catheterization lab
within 90 minutes (called "door-to-balloon" time).
Yet
little headway has been made on the other side of the hospital
door: getting patients to
recognize symptoms and act on that knowledge by getting to the
hospital ASAP.
Delay in Getting Treatment for Heart
Attack: Results of the TRIUMPH Study
A significant portion of patients having
a heart attack (a million people annually in the United States) do
not receive
the optimal treatment because they do not get
to
the
hospital
at
all,
or they
delay, putting them outside the 90 minute window. Often this
is because people are not aware of the warning signs or symptoms of
a
heart attack,
or
their
symptoms
may
be atypical,
or they are in denial. These issues are well-known and well-documented.
But this week's JAMA study documents for the first time how the issues
of money, insurance and financial concerns impact the clinical outcomes
from AMI.
Dubbed the TRIUMPH
study (Translational
Research
Investigating Underlying Disparities in Acute Myocardial
Infarction
Patients' Health
Status) the JAMA article was authored by a group of investigators,
headed by Kim G.
Smolderen, Ph.D., of Tilburg University, Tilburg, the Netherlands,
who looked at a registry of 3,721 AMI patients enrolled between
April 2005 and December 2008 at 24 U.S. hospitals. Patients were categorized
into three groups: those with full medical insurance who had no
financial concerns about accessing health care; those with insurance
but with financial concerns; and those with no insurance. Patients
were also divided into three other groups,
based on how long
it took them to go to the hospital: equal to or less than
2 hours, between
2 and 6 hours, or greater than 6
hours. The results were clear: almost half the uninsured patients
waited more than 6 hours to go to the hospital, compared to 39%
of the fully insured patients and 45% of those insured but with
financial concerns. Likewise, patients who arrived quickly, in 2
hours or less, were more likely to be the fully insured (37%) --
with 34% of those insured with financial concerns and 28% of the
uninsured getting there in 2 hours.
Public Health Implications of Delayed Treatment
The authors of the study stated:
"Because prehospital delays
are associated with higher AMI morbidity and mortality, demonstrating
that patients
with
no
insurance
or those
with insurance but reporting financial concerns about accessing
care are at higher risk for prehospital delays is important because
it
would suggest that reducing financial barriers to care -- perhaps
through expansion of benefits or health insurance coverage --
could reduce delays and improve outcomes.
"These findings underscore
important
consequences from inadequate health care insurance coverage for
the substantial number of individuals in the United States experiencing
AMIs. The data also suggest that efforts to reduce prehospital
delay
times may
have limited impact without first ensuring that access to health
insurance is improved and financial concerns are addressed in
patients who seek
emergency care."
Increased morbidity from a heart attack translates
into a patient whose heart becomes irreversibly damaged due to lack
of oxygen -- needlessly in most cases because angioplasty has the
ability
to
avoid this scenario, if performed soon after symptoms begin. Patients
with damaged heart muscle have less energy, they may need to stop
working, go on disability and they will most likely require future
hospitalizations for chronic heart failure, further burdening the
healthcare system,
not to mention causing premature death and significant impact on
their families -- a tragic prognosis, especially since the means
to avoid
this exists
in any hospital equipped to perform emergency angioplasty.
Important Messages from the TRIUMPH Study
One obvious take-home message from this JAMA study is the urgent need
for health care reform in the U.S. -- the creation of a system where
the fear of being bankrupted just for
walking
into
the Emergency
Room has been removed. The U.S. Emergency Medical Treatment
and Active Labor Act ensures that patients will receive care during
emergency medical conditions, regardless of insurance
coverage. But there is no guarantee that patients
will be able to afford such treatment. More is needed, as pointed
out by Dr. Ralph Brindis, President of the American College of Cardiology:
"As the D2B Alliance has shown
us, optimal AMI care involves receiving treatment within the
first 90 minutes of arriving at the hospital. But the improved
outcomes this speedy treatment can provide are limited if the
patient waits more than six hours to come in for treatment. The
recently passed health care reform law could help out in this
regard. Through its insurance reforms, it is predicted that millions
will gain access to health insurance...we
potentially have a unique opportunity to help improve outcomes
for patients with emergency conditions by reducing delays in
treatment, and reducing the stress that comes with having to
choose between seeking treatment and maintaining financial stability."
Ralph Brindis,
MD, FACC
However, Dr. Brindis and other cardiologists make
another very critical observation about this study's results: almost
40% of those patients who were insured, who had no financial concerns,
took more than 6 hours to get to the hospital!
This large number signals
a problem not only in symptom recognition, but also with public
education
about how important getting timely
treatment is. If people realized how successful modern treatment
of heart attack is, they might be more motivated to get to
the Emergency Department without delay.
In this video, made during the 30th Anniversary of Coronary
Angioplasty meeting in 2007, Dr. William O'Neill, one of the
pioneers of the treatment of heart
attack
using
angioplasty,
and Dr. Ted
Feldman of Evanston Hospital in Illinois, discuss how angioplasty "has
taken the dread factor out of heart attacks".
With a combination of increased insurance coverage
for patients, along with a strong public education effort, it may
be possible to reduce significantly the negative effects of heart
attack on both patients and society.
