Heart Therapy Effort Hits Snag

MetroHealth, EMS not enough evidence to alter treatment


 
 

Harlan Spector | | Tuesday, March 24, 2009


CLEVELAND -- Regional cooperation among hospitals on a potentially lifesaving treatment for people who collapse from sudden cardiac arrest is in doubt because MetroHealth Medical Center and Cleveland Emergency Medical Services do not support it.

In Columbus, New York City and several other cities, ambulances take cardiac arrest patients whose hearts have been restarted by electric shock - but who remain unconscious - to hospitals that provide a cooling therapy that lowers the body temperature.

Most of these patients die from brain damage, but doctors have found that lowering their body temperature by about 8 degrees for 12 to 24 hours protects the brain and can save lives.

Doctors at University Hospitals Case Medical Center are advocating a systemwide approach to get these patients to hospitals that provide cooling therapy.

But MetroHealth and Cleveland EMS officials say they aren't convinced the therapy is proven enough to rewrite the book on cardiac arrest treatment.

The American Heart Association recommended cooling for most cardiac arrest survivors after two small studies in Australia and Europe, published in 2002, showed a clear benefit. The therapy is targeted at patients stricken by ventricular fibrillation, an electrical disturbance that causes the heart's pumping chambers to quiver instead of pump. It's the most common cause of sudden cardiac arrest.

Many hospitals and cities have been slow to adopt the heart association recommendations.

Dr. Arie Blitz, a UH heart surgeon and president of the heart association's Cleveland chapter, is calling for a Columbus-like system here.

Columbus rescue workers start the cooling process with intravenous cold saline and ice packs placed in the armpits and groin. Hospitals take over with more sophisticated cooling equipment. Some Cleveland-area hospitals have looked at inflatable suits that circulate cold water.

"I am still amazed that lots of physicians are not aware of the technology," Blitz said in an e-mail. "And if they are aware, they are not using it."

Despite often heroic efforts to save cardiac arrest victims with CPR and defibrillation, two out of three who regain a pulse but don't wake up don't survive to hospital discharge. Even those who do are often neurologically impaired.

"In the past, we thought this was a hopeless cause," said Dr. Michael DeGeorgia, UH's director of neuro-intensive care and a proponent of cooling therapy. "We know now there's a lot we can do about it. Now, we cool patients and they walk and talk and go home."

Doctors say they don't fully understand why cooling works. But the process protects the brain from damage caused by a cascade of biochemical reactions that occur when circulation is restored.

UH is working out procedures for its emergency department and Cleveland Heights EMS crews. The Cleveland Clinic also is looking at cooling equipment for all its system hospitals, said Dr. Thomas Tallman, an emergency doctor and Clinic EMS director.

But Dr. David Rosenbaum, director of MetroHealth's heart and vascular center, said there is not enough research data to justify a regional system. Rosenbaum, a heart rhythm specialist, also challenged whether cooling is a priority, considering that heartbeat is restored in only a small number of people who suffer cardiac arrest outside hospitals.

With more than 300,000 deaths a year in the United States from cardiac arrest, Rosenbaum said the focus should be on preventing deadly rhythm disturbances and improving access to defibrillation.

"The more upstream the interventions are, the greater impact they will have on sudden death," Rosenbaum said. Cooling "at best can have really a small impact on the bigger problem."

MetroHealth would play an important role in a coordinated system because of its high patient volume and its medical oversight of Cleveland EMS.

Cleveland EMS Commissioner Edward Eckart said that based on advice from Dr. Thomas Collins, city EMS medical director and a MetroHealth emergency doctor, the city has no plans to carry cooling equipment or transport patients only to hospitals that provide the therapy.

Eckart said the city has not been approached about starting a program, but he agrees the medical research on lives saved is not strong enough to shift gears. The city now takes cardiac arrest survivors to the closest hospital capable of emergency angioplasty (a treatment for heart attacks, which often happen in tandem with cardiac arrest).

A regional approach to cooling "is not something we believe right now is worth taking on," Eckart said.

Cooling therapy is part of a larger push to improve dismal survival rates from cardiac arrest.

Chances of surviving depend largely on where you live. For example, patients treated in large, urban teaching hospitals have better odds than those treated elsewhere, according to research from the University of Pennsylvania School of Medicine published last month.

And people in cities that have pushed cardiac arrest as a public health imperative - focusing on bystander CPR training, defibrillation programs and EMS response - also fare better.

Cities such as Seattle report survival rates above 35 percent for ventricular fibrillation arrests - the type that can be corrected with defibrillation. But the national average is about 4 percent.

In 2007, UH's Blitz, calling the gap in survival rates an embarrassment, pressed Cleveland hospitals and EMS officials to join a national program to track outcomes and improve survival. City officials do not know the survival rate here, according to a spokeswoman. But she said Cleveland plans to join the national program, which is supported by the heart association and the federal Centers for Disease Control and Prevention.

Columbus already is part of the program, called Cardiac Arrest Registry to Enhance Survival. The city's survival rate is 12 percent, and it is expected to improve with a citywide cooling program adopted last July, said Dr. David Keseg, the Columbus EMS medical director.

Columbus handles about 500 cardiac arrests a year. "All our hospitals have signed on to cooling, so we haven't had to establish resuscitation centers," Keseg said. Asked about outcomes, he said results wouldn't be available until the program reaches one year.

Though it's not unusual to have debate over new therapies, the benefits of induced hypothermia is not a new discovery. Napoleon's medics were said to ice soldiers to preserve injured limbs 200 years ago. Cooling was tested as along ago as the 1950s for cardiac arrest survivors. Today, it's used routinely to reduce complications of heart surgeries, and it has shown promise for stroke and spinal injuries.

Blitz uses a cooling device during some surgeries, and he has received research money from the device maker, Alsius Corp. of Irvine, Calif.

Blitz said the debate should be aired publicly, and he is not rattled by opposition to a regional approach.

"I think the data shows that for patients who have cardiac arrest and are not waking up, there's very little downside" [to the cooling therapy,] he added. "Why not offer them something?"




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