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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. catheterization laboratory


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:

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) 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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