Real World Health Care Blog

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It’s Not Over Yet: Addressing Part Two of the Door-to-Balloon Time Initiative’s Success

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John P. Reilly, M.D., FSCAI

From the very first sign of a heart attack, the clock starts ticking in the race to save a patient’s heart muscle and even his or her life.

Thanks to technology and finely tuned systems of heart attack care that are now available in communities throughout the United States, we are getting faster all the time.

But sometimes we still lose the race.

During a heart attack, the heart is deprived of oxygen. The longer the heart goes with too little oxygen, the more muscle is lost, often irreversibly. This is what doctors mean when we say, “Time is muscle.” How quickly a patient receives treatment once heart attack symptoms appear often determines if he or she will make a full recovery, suffer heart muscle damage, or die.

Door to Balloon Signaled Success, or Did It?

This is why, a decade ago, healthcare professionals across the country set out to reduce the time it takes to treat heart attack patients once they arrive at the hospital. Since stopping a heart attack often involves balloon angioplasty to reopen the blocked artery, the effort was called the Door-to-Balloon (D2B) Initiative. This effort has prevented or limited heart damage for countless patients.

The D2B initiative involved making the healthcare system more efficient, more responsive and more effective, starting from the moment a heart attack patient comes to the attention of an emergency medical responder (EMR) answering a 9-1-1 call or presenting in the emergency department.  When D2B began, it often took more than two hours from the time a heart attack patient arrived at the hospital until he or she received life-saving treatment to reopen a blocked artery.

Now, 90 percent of patients who enter hospital doors receive treatment in less than 90 minutes and many are treated within 60, 30, even 15 minutes. [1]

D2B is one of healthcare’s greatest success stories. But, according to a new study [2], reducing D2B times has not been enough to significantly reduce mortality rates among heart attack patients.

What Happens Before the Hospital Door?

There are two sides to the time equation. Unfortunately, the part of the equation that has not improved enough is how long it takes patients to get to the hospital once heart attack symptoms start. Most patients wait two or more hours after heart attack symptoms appear to seek medical help. [3] Many patients are taking too long to call 9-1-1, placing themselves at risk of suffering irreversible heart damage or death.

We must do for Symptom-to-Door (S2D) Time what we have done so successfully for D2B. Revamping a system of care outside the hospital, however, is much different and perhaps more difficult than revamping a system of care within the hospital.

There have been myriad heart attack awareness programs, including online public education programs like SecondsCount.org, for which I am an editor, aimed at helping people understand the risks of heart attack, how to recognize the symptoms and why responding promptly is essential.

We have made progress. An increasing number of people know that chest pain, shortness of breath, nausea, fatigue, dizziness, and pain in the jaw, back or arm are often the first signs of heart attack. While I see more people who identified their symptoms early on, there are also many who remain unaware, are in denial or are just confused. Every day, I see patients who thought their symptoms “weren’t that bad” or explain them away as indigestion or a virus. I also see the toll that lost time takes in hearts damaged and lives lost.

Only 60 percent of patients contact emergency medical responders when experiencing symptoms. About 40 percent arrive at our hospitals on their own. [4] That’s dangerous, whether the patient is driving him- or herself. Or, even if a friend or relative is driving, it still represents a lost opportunity for treatment to begin in the ambulance, or to alert the doctors in the emergency room that a heart attack patient is on the way in.

Let’s Save More Hearts and Lives

To get started, here are a few thoughts on how we might reduce S2D:

  • We need a concerted national effort to reduce S2D time that establishes consistent messages rather than myriad programs offering incomplete or inconsistent information.
  • We must improve regional and statewide systems of care to coordinate heart attack care to ensure everyone gets the most expeditious care.
  • We need to better inform the people who are most at risk for heart attack or other heart issues about what symptoms to look for and what to do if they develop.
  • And, of course, we must continue our educational efforts, helping everyone to understand that if they are concerned they may be having a heart attack, then they should call 9-1-1 without delay and without concern about looking foolish if their symptoms turn out to be something other than a heart attack.  The alternative – sitting at home while having a heart attack, with heart muscle dying as the minutes tick by – would be far worse.

We’ve had remarkable success in reducing D2B times. But it’s not enough. To save hearts and lives, we must take on the other side of the heart attack challenge.

We’ve done it once. We can do it again.

1. Bates ER, Jacobs AK. Time to Treatment in Patients with STEMI. N Engl J Med 2013;369:889-892.
2. Menees DS, Peterson ED, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med 2013;369:901-9.
3.  Life After a Heart Attack. National Heart, Lung, and Blood Institute.
4.  http://nypress.com/forty-percent-do-not-call-911-survival-rates-show-every-minute-matters/, http://www.nejm.org/doi/full/10.1056/NEJMp1308772

The President and His Stent: How the Patient-Physician Relationship Represents What Works Best in U.S. Health Care

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Dr. Ted A. Bass

The decision by former President George W. Bush and his doctors to treat a blockage in one of his heart arteries with angioplasty and stenting has become the newest chapter in the intense debate over appropriateness in stenting.

Bush’s physical examination revealed irregularities that led to tests that revealed a blockage in his coronary artery, which Bush and his doctors decided to treat with a stent, according to his statement. That he was not having a heart attack and apparently had not felt any symptoms, such as chest pain, brought objections from those who would place sharp limits on the use of stents.

Only President Bush’s physicians and family know what alternative therapy choices were presented to Bush, but we do know medical advances allowed him to choose from several therapeutic courses. Bush, in consultation with his doctors, chose the one that was right for him and the quality of life he wished to maintain.

High quality medical care is patient-centered. We strongly value the right of patients, with their doctors, to make informed choices in line with their health and quality of life goals. This right is threatened by critics who would “reform” the health care system by ignoring the complex nature of medicine, cardiovascular disease and the individual needs of each patient.

For those who are quick to dismiss the benefit of stents, I would encourage them to speak to our patients. As a practicing interventional cardiologist, I see first-hand the benefits of interventional cardiology procedures. I see it when a patient’s life is saved during a heart attack, in infants born with a serious heart defect whose hearts beat strong because of advances of interventional care and in seniors who enjoy productive lives again after a minimally invasive heart procedure. In patients with stable coronary artery disease, stenting reduces chest pain from poor circulation of the heart arteries, decreases the need for repeat procedures, and improves the overall circulation of the heart.

And this is what the President Bush case demonstrates:  Health care decisions must be made between the patient and his or her doctor. As outsiders in the Bush case, we do not presume to make that decision for him – nor should others. While it is important to review patient cases to continually improve, learn from and advance the science of medicine, we must not judge the appropriateness of a medical decision on the basis of limited information. To do so is to rush to a judgment that is short sighted, uninformed and, ultimately, emphasizes attention-seeking soundbites over patient care.

In our quest to reduce costs and ensure that appropriate and optimal treatment is provided to each patient and is in step with the guidelines, let us not forget the doctor-patient relationship at the heart of all we do as physicians. It is a fundamental trust that must not be jeopardized.

Now tell us what you think. Do you agree that stents are beneficial to patients? Why or why not? What does the case of President Bush illustrate in terms of the doctor-patient relationship?