Cardiac & Resuscitation, News

Cardiac-Response Plan Charts Positive Results in San Diego

SAN DIEGO — Patients with the most lethal type of heart attack are receiving lifesaving care in half the time as before 2007 under a cardiac-response system launched early last year, county officials said yesterday.

Now, paramedic ambulances carry special equipment that allows them to diagnose these heart attacks in the field. The paramedics then call any of 13 designated hospitals’ heart attack teams to let them know a patient will soon arrive so they can be prepared, said Dr. Bruce Haynes, medical director of the county’s Emergency Medical Services.

In the years before the Cardiac System of Care was created, patients would arrive at the emergency room and have to wait 125 to 140 minutes before they could go into a cardiac catheterization lab and have their artery blockages cleared, Haynes said.

That time was reduced to 62 minutes during the first year of the program, which was launched in January 2007. “Medical research shows this saves lives and is truly a great benefit,” Haynes said.

He said 330 patients benefited from the new system in 2007.

Haynes, hospital cardiologists, paramedics and county officials held a news conference yesterday to announce its success. County officials said they don’t know how many deaths the program prevented or how many patients had less damage to their heart muscle because blood flow was restored faster.

But county Supervisor Greg Cox said he is sure the system has made a lifesaving impact. “Today, heart attack victims have a much better chance to survive and recover,” he said.

One of the first patients to benefit from the cardiac system was Ron Rosenbaum of San Marcos, who experienced pain in his arm a year ago and went to a Carlsbad fire station to get checked out.

The station hooked him up to an electrocardiogram machine and immediately determined he was having a type of heart attack called ST-segment elevation myocardial infarction, or STEMI. He was promptly transported to a hospital where heart specialists awaited.

“It was no time at all before I was in the cath lab … and had two stents put in,” Rosenbaum said. “I didn’t realize then, but I do now, how lucky I was with this system. If they didn’t have their specialized team there … I might not be lucky enough to be standing here.”

One reason for delays in the old system is that paramedics would routinely take symptomatic patients to the nearest hospital, regardless of whether it had a cath lab team ready to go, seven days a week, 24 hours a day. Paramedics didn’t know which patients were having a true heart attack.

“We used to fly blind, without knowing the true condition of the patient,” said Paul Maxwell, a county paramedic.

The improvement brings the county to a speed called a door-to-balloon time that is even faster than the national target of 90 minutes. Hospitals across the country have been dramatically reducing their times as well. Two years ago, the national goal was 120 minutes.

Part of the success of the new system is that every ambulance with a paramedic in the county now carries a 12-lead electrocardiogram machine, county officials said. These devices can identify STEMI heart attacks.

In a STEMI, the artery is completely occluded, causing heart muscle downstream to die rapidly, said Dr. Paul Phillips, a cardiologist at Scripps Mercy Hospital in Hillcrest and one of the first to advocate the new system.

STEMIs are also called “tombstones” in part because of the heart waves’ appearance on a printout. About one in every three heart attacks is classified as a STEMI.

The blockages almost always occur in the left ventricle, and they’re far more likely to cause death more quickly than most other kinds of heart attacks.

Each year, about 400,000 people in the nation suffer a STEMI, according to the American Heart Association. Many of them die without reaching the hospital.

Non-STEMI heart attacks are less urgent because they are usually caused by clots or blockages that haven’t blocked blood flow entirely.

“You could say that other kinds of heart attacks, your kitchen sink is draining slowly, but it’s still draining. But with a STEMI, there’s no flow at all,” said Ori Ben-Yehuda, director of the Coronary Care Unit at UCSD Medical Center in Hillcrest.

The most effective way to treat a STEMI is prompt catheterization. Of the nearly 5,000 acute-care hospitals in the United States, fewer than half have catheterization labs and only 1,200 have equipment and specialized teams ready to do such procedures.

In San Diego County, paramedics don’t automatically route non-STEMI patients to one of the 13 hospitals participating in the cardiac-response program.

Non-STEMI heart attacks are tougher to identify. Their symptoms can resemble those of indigestion, anxiety or other problems. That’s why health experts say that people who suspect they’re having a heart attack should call 911 instead of going to the hospital themselves.

The countywide cardiac-response system was made possible in large part because of a $536,000 gift to the city of San Diego from La Jolla stock adviser Jack White, who suffered a STEMI heart attack in 2004. When paramedics arrived at his home, they couldn’t diagnose him because they lacked the 12-lead equipment, he recalled.

“They told me the city hadn’t been able to fund them to buy it, and how important it was to get this equipment because every second after a heart attack, a little more muscle is destroyed,” White said in a 2006 interview. “So I asked them how much money it would take.”

Ambulance companies, hospitals and fire departments have provided most of the remaining financial support.

Hospital officials around the county are delighted with the system.

“There’s no question that the quality of care given to people having heart attacks in this county has improved,” said Dr. Jerrold Glassman, a cardiologist and chief of staff at Scripps Mercy Hospital in Hillcrest.

Palomar Pomerado Health pioneered the STEMI-response concept in San Diego County in November 2003. Its ambulances were the first to have the 12-lead electrocardiogram machines.

Before November 2003, the average door-to-balloon time for patients using the 911 system was 136 minutes. Today, the time is 72 minutes, said Andy Hoang, a spokesman for Palomar Pomerado Health.

“That’s a huge difference,” Hoang said.


The 13 hospitals participating in the Cardiac System of Care are:

Alvarado Hospital in San Diego
Palomar Medical Center in Escondido
San Diego Naval Medical Center in Balboa Park
Scripps Memorial Hospital in La Jolla
Scripps Memorial Hospitalin Encinitas
Scripps Mercy Hospital in Chula Vista
Scripps Mercy Hospitalin Hillcrest
Sharp Chula Vista Medical Center
Sharp Grossmont Hospital in La Mesa
Sharp Memorial Hospital in Kearny Mesa
Tri-City Medical Center in Oceanside
UCSD Medical Centerin Hillcrest
UCSD Thornton Hospital in La Jolla