Treatment of Heart Attack
and the Realities of Angioplasty
By Malcolm Brand, MD, FACC
In April 2007, the New York
Times ran an article entitled "Lessons of Heart Disease, Learned and
Ignored." The article profiled a Boston cardiac patient who suffered a serious heart attack
when a large blood clot in his left anterior descending artery blocked the flow
of blood to most of his heart. His life was saved at
Brigham and Women's Hospital by an emergency interventional procedure called
angioplasty, which opened the blocked artery.
The article has generated questions in our community about local treatment for
heart attack patients, angioplasty, and specifically, why angioplasty is not
available at Cayuga Medical Center.
In treating myocardial infarction (heart attack), the goal is to open the
blocked artery as quickly as possible because every minute of delay loses heart
muscle. Opening the blockage is done one of two ways. The first is thrombolytic therapy, which uses drugs such as tPA (tissue Plasminogen
Activator) to dissolve the blood clot. The second is angioplasty, during which
an interventional cardiologist inserts a balloon into the blockage to break it
up and then places a stent at the site of the
blockage to hold the artery open.
Does Cayuga Medical Center have plans to offer angioplasty?
Local cardiologists and Cayuga Medical Center are eager to offer angioplasty to the community we
serve. However, the decision regarding whether or not angioplasty services are
available in Tompkins County is not made at the local level; it's
made at the state level by the New York State Department of Health. We
have a very fine cardiac catheterization program at Cayuga Medical Center and perform more than 400 cardiac catheterizations a
year. We have been working diligently with the state to make angioplasty
available here because we have a good record and we believe local angioplasty
services would be safe and beneficial to our patients.
As the Times article pointed out, less than 25 percent of the nation's
acute-care hospitals offer angioplasty. It's typically available only in larger
cities at major medical centers where there is a cardiac surgery program, as
well. Currently New
York State has four centers that offer urgent angioplasty in
sites that don't have cardiac surgery backup on the premises. This is a
relatively new development that New York State is closely monitoring for safety
and patient outcomes before allowing other centers (such as Cayuga Medical
Center) to offer angioplasty.
Which is better treatment for a heart attack, angioplasty or thrombolytic therapy?
Statistically, angioplasty has a slight, but real, advantage in saving lives
and heart muscle. Thus, if both procedures are equally available in a timely
fashion, angioplasty is the recommended choice for treatment in the vast
majority of cases.
However, if angioplasty is not initiated within 90 minutes of the onset of
heart attack symptoms, the statistical advantage is lost. If you live in Ithaca,
New York, you need to travel 45 to 60 minutes (longer in
winter weather) to the closest center offering angioplasty. The likelihood of
making that 90-minute treatment window during a transfer from Ithaca is low -- not due to lack of effort and efficiency,
but due to geography.
For patients who live 60 minutes or more from an angioplasty center, the timely
use of a clot-busting medication to open the artery, followed by cardiac
catheterization and stenting (if appropriate), is
equal in effect to angioplasty for which you must travel out of town.
When do you transfer heart attack patients to another hospital?
Transferring a patient in the middle of a heart attack in an ambulance carries
inherent risk, especially in the snow. The decision to transfer a patient has
to be made based on what's best for the patient and
the care that is available in Ithaca. Right now, we treat heart attack patients with thrombolytic therapy and then evaluate for evidence that
the artery has reopened.
If there is evidence that the artery has not reopened within a certain period
of time, then the benefits of transfer outweigh the risks of transfer and
out-of-hospital care during an ambulance ride. These decisions are not dictated
by hospital reimbursement issues, as suggested in the Times article; rather,
they are dictated by a patient's condition and what the attending cardiologist
feels is in the best interest of his or her patient.
Dr. Brand is board certified in cardiovascular disease, nuclear cardiology, and
internal medicine, and is a Fellow of the American College of Cardiology. He is director of Cardiac
Catheterization at Cayuga Medical Center and is in practice with Ithaca Cardiology Associates,
where he can be reached at 607-272-0460.
