Heart attacks, or myocardial infarctions, represent one of the biggest worldwide killers. This has prompted medical organizations to seek improved treatment initiatives to quickly tackle the issue. Unfortunately, if a recent study is to be believed, an initiative aimed at faster heart attack treatment times has failed to reduce the number of deaths.
Heart attacks are the result of dysfunction in the supply of blood to the myocardial tissue, typically resulting from Coronary Artery Disease (CAD). CAD occurs when plaque formations accumulate within the lining of the coronary arteries, impeding bloodflow to the cardiac muscle. Once this occurs, the lack of oxygen causes the heart tissue to die (ischemia), ultimately, leading to sudden death. If the event is detected and treated rapidly, the patient may recover, although cardiac scarring and dysfunction is likely.
The Door-to-Balloon Time
The traditional train of thought has always been that early intervention is critical to a patient’s outcome.
Current guidelines indicate that patients displaying a particular form of heart attack should be treated within a maximum time-frame of 90 minutes, between being admitted to emergency care departments and receiving treatment (the door-to-balloon initiative [D2B]).
Treatment involves moving a deflated balloon into the blocked coronary artery, starting from the femoral artery of the groin. Once in place, the balloon is inflated to return a decent bloodflow and a metallic stent is put in place to keep the artery open.
A recent study, published in the New England Journal of Medicine, sought to investigate whether this massive, government-sanctioned D2B initiative was actually saving additional lives. In order to achieve this, the research team investigated the relationship between door-to-balloon times and the number of deaths recorded inside hospitals, looking at over 96,000 admissions (from over 500 hospitals) for patients with a deadly type of heart attack (ST-segment elevation myocardial infarction).
The group did find that D2B times had improved greatly amongst those hospitals investigated. Sadly, however, the initiative did not seem to improve recent in-hospital mortality rates, when comparing the (for example) patients who had a D2B time around the 80 minute mark to patients with D2B times that were much lower.
However, over the 90 minute threshold the risk of death from heart attacks is doubled; however, this appears to be the “limit,” where reducing the D2B times any further had no statistical impact upon mortality.
For example, the study’s first year death rate was five percent, when the D2B time was 83 minutes. Three years down the line, the D2B time had dropped to just 67 minutes, but the death rate was 4.7 percent, a barely perceptible difference.
Symptoms Risk Factors of Heart Attack
Obvious, characteristic signs of heart attack include the following:
- Jaw, neck, back and upper stomach pain
- Fatigue, weakness, light-headedness
- Chest pain
- Shooting pains/discomfort in the arms or shoulder
- Shortness of breath
- Cold sweats
A variety of different factors can increase an individual’s propensity to developing a heart attack. Elevated levels of “bad” cholesterol (high density lipoproteins), caused by certain genetic abnormalities and lifestyle factors, can clog up coronary arteries. This is exacerbated by poor lifestyle choices, including smoking, alcohol consumption, an unbalanced diet, reduced physical activity and obesity.
Determining effective, efficient treatment strategies in a timely manner is critical to tackling the problem, which has become the predominant cause of death globally. In America alone, 600,000 people die annually from heart disease, representing one in four of all deaths. According to the Centers for Disease Control and Prevention (CDC), over 108 billion dollars is lost due to heart disease every year, accounting for medications, health care treatments and reduced productivity.
According to the research team, more resources should be devoted towards other areas, including teaching the general public about the typical symptoms witnessed during a myocardial infarction.
According to the CDC, a recent study suggested that respondents to a survey were well aware that chest pain was one of the classic symptoms of the onset of heart attacks. However, only 27% were aware of all of the potential symptoms encountered during such an event. Another research group cited patient response time as being a significant hurdle in treating infarctions, as 47% of people who had died from sudden cardiac events had not been hospitalized; this suggests that people were not reacting quickly enough to ensure they reached the hospital in good time.
As a result, healthcare organizations must attempt to limit the overall ischemic time, and try to reduce the time between when symptoms first manifest and treatment with balloon angioplasty – not just the time between admission and treatment.
On this basis, the question must be, how quickly can patients identify the symptoms and how quickly can paramedics get heart attack sufferers to the hospital?
According to Reuters, this notion is supported by Dr. Hitinder Gurm of the University of Michigan, who was the study’s co-author. He maintains heart muscle death begins to perish at the onset of the patient’s symptoms and continues to die until the artery is widened, during treatment. He asserts:
“…most of the delay happens before the patient comes to the hospital.”
So, below the 90 minute deadline, the study seems to suggest that faster heart attack treatment times fail to make a significant difference to the death rate. However, breaching the 90 minute mark results in a far different outcome. It seems hospitals are now at the peak of their efficiency, and other strategies are now required to reduce the mortality rate even further of the world’s biggest killer.
By: James Fenner