CLEVELAND -- There was a time when ambulances sped heart attack patients to the closest hospitals.
But a push is under way to get patients to the right hospitals. For severe heart attacks, that means hospitals with around-the-clock capability to perform emergency angioplasty within 90 minutes.
Many hospitals in the Cleveland area are doing just that. But experts say what is lacking is a systemwide approach. Just as gunshot and accident victims are certain to be taken by air or ground to designated trauma hospitals, doctors say patients having major heart attacks should go to designated heart attack hospitals.
These hospitals mobilize teams that take patients from the ambulance to catheterization rooms, where balloons loaded onto catheters pop open obstructed coronary arteries, and stents are placed to keep them open.
The procedure is not essential for all heart attacks.
Most heart attacks involve partial blockages that don't show up on electrocardiograms.
Emergency angioplasty is for the big ones -- complete blockages that interrupt circulation to a large part of the heart.
For these patients, angioplasty yields far better outcomes than clot-dissolving drugs used since the 1980s. The intervention saves more lives and prevents more recurrent heart attacks and strokes.
Yet doctors say not enough patients get the treatment in time -- or get it at all.
"I think there has to be systematic changes," said Dr. William Lewis, a MetroHealth Medical Center cardiologist. "We have to do better than we're doing."
The American College of Cardiology has set a goal of getting 75 percent of major heart attack victims to catheterization within 90 minutes of arrival at a hospital. Sixteen hospitals in Cuyahoga, Summit, Lorain and Lake counties have signed on as participants in the college's initiative, called the "D2B (door to balloon) Alliance," to meet that goal. The American Heart Association is a partner in the effort. Nationally, only 25 percent of hospitals are capable of doing emergency angioplasty, Lewis said.
Ohio Emergency Medical Services, which is part of the state Department of Public Safety, is working with medical groups to determine which hospitals provide timely treatment.
"We need to know what the capabilities of the hospitals are," said Dr. Carol Cunningham, a Lake County emergency physician and state EMS medical director. "We want to see if our triage and transport protocols need to change."
Right now, smaller hospitals that don't provide emergency angioplasty often transfer patients to larger hospitals that do. In the eastern suburbs, for instance, helicopters lift patients from Geauga, Euclid and South Pointe hospitals to Hillcrest in Mayfield Heights, which calls its heart attack program "Code Crimson."
Dr. Daniel Walsh of EMH Regional Medical Center in Elyria said he expects EMS regulations ultimately will require heart attack patients be taken to designated hospitals, which will cut down on transfers and save time.
Several regions, including Boston, have taken this approach. But proponents face a complicated set of issues that involve not just hospitals, but coordination among medical helicopter services, dozens of EMS departments and patients themselves:
On the technical side, some say that an important tool to beat the clock is the ability of EMS units in the field to transmit EKG data to doctors. When an EKG shows an "ST elevation," which indicates a severe blockage, the real-time information allows hospitals to mobilize heart attack teams. But not all EMS departments have the technology.
"By getting that 15-minute heads-up to activate a team, that's a lot of time," said Dr. Daniel Simon, chief of cardiovascular medicine at University Hospitals Case Medical Center.
Another concern in the push to regionalize heart attack care is money. Cardiac medicine is big business. Bypassing hospitals because they lack 24-hour angioplasty -- and cardiac surgery backup (which is mandatory in Ohio) -- means they lose revenue.
"Cardiac care at most hospitals is the No. 1 or No. 2 service line, so you see more hospitals investing in this," said Dr. Christine Zirafi, a cardiologist at Parma Community General Hospital.
But it doesn't make financial sense for small hospitals that see relatively few heart attack patients to invest in 24-hour angioplasty. Even so, these hospitals now benefit from pass-through traffic -- prepping heart attack patients who are transferred elsewhere for angioplasty.
Simon of University Hospitals said bypassing hospitals for designated heart attack centers "has tremendous implications for health systems and their viability."
People with heart attack symptoms often wait too long for medical care. Or when they do act, they get to the hospital on their own instead of calling 9-1-1.
An examination of 772,000 heart attack patients in a national registry showed only half went to the hospital by ambulance, according to a 2002 study in the American Heart Association journal Circulation. Those who called 9-1-1 received treatment faster than those who went themselves.To reach this Plain Dealer reporter: firstname.lastname@example.org, 216-999-4543