Doctors Have Innovative Heart Attack Program

Hospitals push for faster treatment


 
 

Gadi DechterBrent Jones | | Wednesday, October 1, 2008


BURLINGTON, Vt. -- The last thing Erik FitzPatrick remembers of the Corporate Challenge, he was waving to his wife and young daughter as he neared the finish line.

That's when he went down with a massive heart attack. Fortunately, runners behind him in the May 15 road race in Montpelier started CPR, and an ambulance arrived within minutes.

"Evidently, I was dead," said FitzPatrick, 43, of South Burlington.

The next day, he woke up in the hospital. He doesn't remember being resuscitated twice in the street, taken to Central Vermont Hospital in Berlin and then transferred to Fletcher Allen Health Care in Burlington, where physicians opened his clogged artery about 90 minutes after he had been stricken.

FitzPatrick figures he was lucky to have the heart attack where he did, and not while running alone. But the system that got him to Burlington so fast was anything but luck.

Physicians at Fletcher Allen Health Care have been working with their colleagues to provide heart attack patients lifesaving treatment in minutes rather than hours, even if they fall ill in remote parts of the state.

The program uses technology, teamwork and a change in state rules.

Over the last two years, a system has been honed to ensure that all patients who arrive at the Burlington hospital can get needed treatment in 90 minutes, the national goal set by the American College of Cardiology and the American Heart Association.

Now, that 90-minute clock is being expanded to regional hospitals to see that patients who arrive in St. Albans, Morrisville or Berlin can still get the treatment only available in Burlington.

"This is really one of those landmark breakthroughs in emergency cardiac care," said Dan Manz, chief of emergency medical services for the Vermont Department of Health, who helped develop the procedures.

According to 2007 data from 84 teaching hospitals, Fletcher Allen had the fourth-lowest heart attack mortality rate of those facilities, the first time it ranked so highly.

The types of heart attack that need such aggressive treatment are those in which the arteries are completely blocked, a condition called ST-elevation myocardial infarction, or STEMI.

In the more common non-STEMI heart attacks, arteries aren't completely blocked, so some blood is still reaching the heart muscles.

"STEMIs are a fire drill. Every 30-minute interval that goes by, mortality increases significantly," said Dr. Harold Dauerman, director of Fletcher Allen's Cardiac Catheterization Laboratories. "On the other hand, non-STEMI's are not as time-pressured. If you catch them within four to 48 hours of the presentation, they do very well."

The treatment given to STEMI patients is to insert a catheter into a leg artery, feed it into the blocked artery around the heart and then expand a balloon to open the artery. A wire mesh tube called a stent (about the size of a ball point pen spring) is then placed at the spot of the blockage, to keep it open.

The emphasis on opening arteries with the balloon and stent developed in the early years of this decade after it became clear the procedure is significantly better than using clot busting drugs - if the procedure can be performed quickly enough.

The effort to get STEMI patients to the appropriate hospital within 90 minutes is nationwide. Last year, the American Heart Association launched its program "Mission: Lifeline," the goals of which are similar to those being put into practice in northwestern Vermont.

Only about a quarter of all hospitals can do the procedures. And only 8.6 percent of STEMI patients nationally who need to be moved between hospitals receive the procedure within the 90-minute window, said Dr. Alice Jacobs, a cardiologist at Boston University and a past president of the American Heart Association. She's helping lead the Mission Lifeline campaign.

"It really takes a system of care, particularly in rural areas," said Jacobs.

One of the first large areas to develop such a system was in Minnesota. Now 35 hospitals and 11 clinics throughout the state have a system in place to get patients to Minneapolis for treatment, (although not all the hospitals send all their patients to Minneapolis) said Dr. Tim Henry of the Minnesota Heart Institute.

"When I started talking about this there was a lot of push-back," Henry said. "In 2003ish the majority were naysayers."

But the system cut in half the number of heart attack deaths, Henry said. The system also cuts the length of hospital stays and reduces other complications.

Now there are 50 to 60 such systems around the country. The first step to set up such a system at Fletcher Allen was to require that an on-call team that does the angioplasty always be available within 30 minutes. Now, 100 percent of STEMI patients who arrive at Fletcher Allen are treated within 90 minutes.

Patients who arrive at Northwestern Vermont Medical Center are being treated in Burlington about 75 minutes after they arrive at the St. Albans hospital. Times are being reduced from other hospitals as well.

"We work by e-mail directly with all the (emergency department) directors and the ED staffs throughout the region to make sure we have a very slick system, sort of a bat-phone approach, one phone call gets the whole cath lab team here, gets everything going," said Dauerman.

Increasingly, ambulances are equipped with special heart monitors that can determine if a STEMI heart attack is taking place. EMTs are being trained to read the data. In some cases, the information can be transmitted directly to a hospital where a physician can read it.

So, for example, if a person in Stowe has a STEMI heart attack, an ambulance can take them straight to Fletcher Allen, rather than going first to Copley Hospital in Morrisville, as standard ambulance procedure requires.

Making that change wasn't as simple as it sounds.

Vermont rules used to require that ambulances take patients to the nearest hospital, said Dr. John Kaeding, the emergency room director at Copley.

The St. Albans hospital has had about three or four STEMI cases a month since the system was implemented, said Dr. Marc Kutler, an emergency room physician at Northwestern.

The patient who arrives in St. Albans with a STEMI isn't even taken off the ambulance stretcher.

"In a lot of cases we can get the patient out and on the road in less than 15 minutes," Kutler said. "The more you do it, it gets more organized, it gets fine tuned.

Kaeding said that since Copley joined the program earlier this year they haven't had a case, but that's typical of emergency medicine. "You don't see any, then you see three in three days," he said.

For patients too far away to reach Fletcher Allen in time to meet the 90-minute goal, physicians will treat them using a combination of clot-busting drugs followed by the balloon when they reach the hospital.

In retrospect, FitzPatrick, who works for the state of Vermont, said he'd noticed the tightness in his chest during several training runs before he started the Corporate Challenge road race last May. He ate right and exercised and - being so young - didn't consider himself a heart attack candidate.

The he died on the street.

Four months later, he has recovered 100 percent. Blood flow to his heart was restored so quickly there was no permanent damage. He's running again and living a normal life.

"Here he is in this race when he had his cardiac arrest,' said Dr. Matthew Watkins, who treated him at Fletcher Allen. "Then another race started with incredibly high stakes. He went from this race to another medical race for which he got the gold medal."




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