Health: Racing the clock after a heart attack

Balloon angioplasty and the 90-minute deadline

By Malka Eisenberg

Issue of August 7, 2009 / 17 Av 5769

As the EMT’s roll the heart attack patient out of their ambulance and the wheels of the stretcher are locked into place, a clock begins to tick.

For patients who require balloon angioplasty to open a blocked artery, the clock moves even faster. During the procedure a balloon-tipped tube is threaded through to the heart, where it is inflated to clear plaque that is blocking or partially blocking an artery. However, research has demonstrated that the procedure is most effective when performed within 90 minutes of a patient’s arrival at the hospital.

“We know it improves mortality,” said Dr. Jason Freeman, director of interventional cardiology at South Nassau Communities Hospital. “If you open up the blood vessel for them within 90 minutes, patients die less and live more.”

South Nassau Communities Hospital is among the 569 hospitals awarded a Gold Medal in coronary artery disease from the American Heart Association/American Stroke Association’s Get With The Guidelines program. This program ascertains that hospitals comply with current protocol for cardiac and stroke patients.

Rabbi Elozer Kanner, coordinator for Hatzalah of Nassau County and the Rockaways, said that Hatzalah transports most heart attack patients to South Nassau.

“It’s requested by the community at large,” Rabbi Kanner explained. “Balancing closeness and care, this is the one that seems to make it. We’re called when there is an emergency so we generally don’t have the luxury of a longer trip.”

In the case of a dire emergency such as cardiac arrest, protocol requires a patient to be transported to the very nearest hospital.

For balloon angioplasty patients, “There’s a huge push to improve times,” said Freeman.

The average time in South Nassau was 67 minutes in the last quarter, he said.

“Ninety minutes is the cut off point,” agreed Dr. Stephen Green, chief of cardiology at North Shore University Hospital in Manhasset. “The sooner the patient is treated, the less the mortality. Ninety minutes is a reasonable window to mobilize staff to do the procedure, diagnose acute myocardial infraction, get approval from family, get informed consent, and ask questions.”

Huntington, South Side and South Nassau hospitals can do balloon angioplasty, and North Shore provides quality oversight.

“We track how well they are doing and if any emergencies don’t work out well they are transferred to North Shore or LIJ,” said Green.

North Shore, designated a “tertiary hospital,” can perform open-heart surgery and all related procedures, included angioplasty.

“Ninety minutes goes very fast,” Green noted.

“Door-to-balloon in 90 minutes is the Medicare standard that all hospitals have to meet,” explained Donna Moravick, a nurse practitioner and vice president of cardiovascular services of the North Shore-Long Island Jewish Health System. It is infrequent that North Shore-LIJ does not meet the 90-minute time window, she said.

Community hospitals that are not equipped with catheterization labs cannot perform angioplasty. Instead, they process and stabilize such patients and transfer them elsewhere for further treatment.

Mercy Medical Center in Rockville Centre and Peninsula Hospital in Far Rockaway both transfer their heart attack patients.

“Obviously, [a patient] will not make it [to a catheterization lab] in the 90-minute window,” said Dr. Peter Galvin, Peninsula’s chief medical officer.

Dr. Sergio Sokol, chief of cardiology at St. John’s Episcopal Hospital in Far Rockaway, said via email that his hospital stabilizes cardiac patients within 15-30 minutes of their arrival, and that the hospital’s six month survival rate for angina and heart attack is equal to those treated at hospitals that do perform emergency angioplasty.

Symptoms of a heart attack will vary case by case, according to North Shore’s Dr. Green. “Everyone is different and has different sensations.”

“The patient will feel discomfort, not super painful, pressure, a heaviness, usually in the middle of the chest,” he described. “It can radiate but it may not, lasting a half hour or longer. It can go to the left arm, neck or back. They may have breathing problems at the same time, may break out into a sweat or have an upset stomach. It shouldn’t go away in two minutes; two minutes is angina, not a heart attack. It’s consistent for 20 minutes or more. They should seek care.”

Female patients may experience very different, even minimal signs of a heart attack, according to a recent study published in the medical journal Circulation. Researchers studying early female heart attack symptoms found that during a heart attack, 43% of the 515 women studied had no acute chest pain, which is considered to be a hallmark symptom of heart attack in men.

“Patients must realize that they have to call [for help] as soon as they suspect that they have a heart attack,” stressed Dr. Green.