Primary Angioplasty in Treatment of
Acute Myocardial Infarction (Heart Attack)
Dr.
Geoffrey Hartzler describing the 1st time he used
balloon angioplasty to treat a heart attack in 1980 (3:13).
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.
Considerable
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.
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. 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.
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.
Following are a series of links to news
articles and studies about this subject:
Uninsured
or Underinsured Patients Delay Getting Angioplasty and Other
Life-Saving Treatment for Heart Attacks
(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.
(Includes video.)
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)
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)
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)
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 the Journal
of the American Medical Association 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,
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.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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