Faster Care After Heart Attack Fails to Reduce Deaths
One of the most successful efforts in modern medicine, cutting the time it takes to treat heart-attack patients after they arrive at a hospital, has failed to deliver on its most highly anticipated benefit: saving lives.
A study of 96,738 patients experiencing a massive heart attack showed time to treatment was reduced 20 percent to 67 minutes from 2005 to 2009 because of improved coordination among hospital units and emergency workers. Still, about 5 percent of patients died in the hospital in 2009, almost the same as four years earlier when care was slower, according to research in the New England Journal of Medicine.
The findings suggest additional efforts to treat patients faster once they reach the hospital could be in vain and may lead to errors in care, said Daniel Menees, an interventional cardiologist at the University of Michigan Medical School. Instead, public efforts should focus on other approaches, including teaching patients to recognize symptoms and encouraging them to reach out for help more quickly.
“Intuitively, we’ve all believed that the sooner we take patients to the cath lab, the shorter we make those treatment times, the better our patients will do,” Menees said in a telephone interview. “That’s not necessarily true.”
Previous studies that showed faster treatment times saved lives could reflect that patients treated quickly may have more straightforward cases, compared with slower care in people with other ailments that make the decision more complicated, Menees said. The focus on speed has also made the clock the most important element, he said.
Treatment teams activated to care for heart attack patients are false alarms as much as one-third of the time now, Eric Bates, from the University of Michigan, and Alice Jacobs, from Boston University Medical Center, wrote in an editorial accompanying the study. The rush to clear the artery can also short-circuit efforts to diagnose the problem, spot other conditions and get consent, possibly compromising safety, they wrote.
The issue is a critical one for hospitals. The time it takes from a patient’s arrival to get a clogged artery cleared, generally done with a balloon-tipped catheter that’s threaded into the blockage and inflated to open a path for oxygen-rich blood, is called the door-to-balloon time. It’s now considered a key measure of hospital quality and is tied to payments from the U.S. Medicare insurance plan for the elderly and disabled.
“The concept of door-to-balloon as a performance measure should at least raise some eyebrows,” said Menees, the lead researcher on the study released yesterday. “We should consider looking at this a little closer and evaluate it the way we do a new device or a drug.”
More than 250,000 Americans each year suffer the most serious type of heart attack. The lack of blood and oxygen immediately starts to damage the heart muscle cells. With time, the cells die and cause irreparable scarring in the heart. While some patients die before getting help, hospitals have focused on quickly opening the arteries to salvage as much of the heart muscle as possible.
The nation’s hospitals have improved the door-to-balloon time since 2006 when health groups including the American Heart Association and the American College of Cardiology started an initiative to speed care. More than 83 percent of patients are now treated within the recommended 90 minutes, exceeding the original 75 percent goal and an increase from 60 percent four years earlier.
The study shows the success hospitals and doctors have had in speeding treatment, said John Harold, president of the American College of Cardiology. The results won’t change the guidelines, particularly because survival isn’t the only goal for fast care, he said.
Quality of Life
“We are also interested in recovery and quality of life after a heart attack,” he said in a statement. “Time is muscle, and the sooner treatment begins, the less muscle is damaged, which preserves functionality of the heart.”
Ultimately, faster care may reduce the future risk of heart failure and improve quality of life, he said. The area is ripe for further studies, the researchers said.
An area that may yield bigger benefits is encouraging patients to seek medical care more quickly, which would reduce the time the heart spends without sufficient blood flow.
“Heart muscle is dying while a patient is thinking, ‘Is this real?’” said Hitinder Gurm, senior author of the paper and an interventional cardiologist at the University of Michigan. “We’re seeing a fair amount of delay in seeking treatment. That has been harder to fix.”
The study findings don’t mean that heart attacks can be treated more casually, Menees said.
“A patient comes in with chest pain and a blocked artery, I’m going to open it as quickly as I can,” he said. “I’m not willing to say time to treatment doesn’t matter at all. But we can say the improvements that were made didn’t have the effects we hoped.”
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