• Teamwork improving STEMI heart attack care

    January 2011

    More than 10,000 Kentuckians die from heart attacks annually, accounting for one quarter of all deaths in the state. A heart attack occurs when a coronary artery becomes suddenly and completely blocked. Since blood cannot flow through the artery into the heart muscle, the heart muscle begins to die. Prompt treatment is essential to prevent permanent damage or death.


    More than 10,000 Kentuckians die from heart attacks annually, accounting for one quarter of all deaths in the state. 


    Cardiologists differentiate between two types of heart attacks: ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). A STEMI heart attack is the most dangerous type of heart attack, involving a sudden blockage of one of the three coronary arteries that supply blood to the heart. A STEMI is usually recognized by an elevation of the ST segment on an electrocardiogram (ECG). This particular type of heart attack calls for urgent treatment. It is critical that the patient receive immediate therapy to open the artery. Ideally, a coronary angiogram is performed and the artery is opened by balloon angioplasty and kept open with a coronary stent.

    In the case of an NSTEMI heart attack, a patient may also receive stents but time is not as critical. The patient can be stabilized, given aspirin and other medications before being taken to the cath lab, where the life-saving procedures that open arteries are performed.

    Diagnosis of a heart attack can be made by emergency medical technicians in the field, but traditionally the cath lab has not been activated until after the patient is brought into the hospital. Recent research has shown that reducing the time for a patient to receive a balloon angiogram after entering the hospital – called “door-to-balloon time” – can improve outcomes. Percutaneous coronary intervention (PCI), or balloon angioplasty, is typically performed by threading a slender balloon-tipped catheter from an artery in the groin to the blocked artery. The balloon is then inflated, compressing the plaque and dilating the narrowed artery so blood can flow more easily.

    According to guidelines set by the American College of Cardiology and the American Heart Association, PCI should be performed within 90 minutes after the first medical contact by experienced operators. However, fewer than a quarter of the hospitals in the United States can meet this 90-minute standard consistently.


    As much as a one-hour delay [to treatment] increased the risk of death by more than 15 percent. 


    Study explores faster treatment strategies

    UK HealthCare recently investigated strategies for reducing door-to-balloon time using emergency medical services (EMS) to provide field triage for patients. Traditionally, when encountering a patient with chest pain, EMS personnel sent ECGs electronically for physician evaluation. In 2009, UK HealthCare went one step further to reduce door-to-balloon time, allowing EMS personnel to activate the cath lab directly, bypassing the time-intensive process of transferring ECGs. This strategy significantly reduced the time to treatment.

    In a pilot study of patients admitted to UK HealthCare after implementation of this new protocol, researchers compared hospital door-to-balloon time in 10 STEMI patients brought directly to the cath lab by EMS to 10 brought to the emergency department first, then to the cath lab. Most of the subjects were white males over age 50 who smoked and were overweight. Door-to-balloon time was 23 minutes less for the first group. The length of hospital stay was a little shorter for the first group, as well.

    A recent Danish study analyzing patient data from 2002 to 2006 found a direct correlation between hospital door-to-balloon time and mortality. As much as a one-hour delay increased the risk of death by more than 15 percent.

    The UK researchers concluded that decreased hospital door-to-balloon time is likely to lead to improved outcomes for the patient and less damage to the heart muscle. They noted further research is needed to evaluate this model.

  • More information
  • UK HealthCare cardiac services - Gill Heart Institute

    For more information, or to make an appointment with a UK HealthCare physician, please call UK Health Connection at 1-800-333-8874. 

Page last updated: 5/23/2014 11:46:26 AM
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    What the news means for you

    Aggressive treatment of acute heart attacks

    Charles L. Campbell, MD
    Cardiologist

    Wright, Heather, MD At UK HealthCare, we have always had a very aggressive approach to treating acute myocardial infarction and have always been aware that the time to angioplasty is paramount. Recently, EMS has really become focused on their times and how fast they can get patients to the proper institution. EMS personnel actually initiated the conversation about activating the cath lab from the field and reducing the overall door-to-balloon time.


    “It’s important for people to recognize the symptoms of a heart attack – chest discomfort associated with shortness of breath, nausea and lightheadedness, and pain that may radiate to the neck or arms and usually worsens with exertion. Call for an ambulance immediately.” 


    The technology EMS can take to the scene has greatly improved. ECGs and software are so much better that experienced paramedics can make the call to activate the cath lab. The beauty of our system is that EMS doesn’t have to buy anything. They are already equipped with their own devices. All they need is a cell phone. The call to the hospital activates the STEMI team, which includes an interventional cardiologist, cath lab personnel, rapid response nurses and an emergency department physician.

    Of course, not every hospital is equipped with a cath lab. In Lexington, you’re always going to be close to one that is. In Clark and Madison counties, as well as many others in Kentucky, a trip to Lexington will be required. In many of these cases, UK HealthCare uses a combination of ambulance personnel and a medical helicopter.

    Diagnosing a STEMI

    It’s important for paramedics to be able to distinguish between a STEMI and NSTEMI heart attack. The STEMI, by definition, shows up on the ECG. In some cases, EMS personnel may encounter a patient who is in shock and looks really ill. Our rule is, when in doubt, activate the cath lab. Both STEMI and NSTEMI patients get stents. The difference is, damage is more extensive in the former, so time is of the essence.

    It’s important for people to recognize the symptoms of a heart attack – chest discomfort associated with shortness of breath, nausea and lightheadedness, and pain that may radiate to the neck or arms and usually worsens with exertion.

    Call for an ambulance immediately. Never drive yourself to the hospital when you’re having chest pains. Women may have slightly different, more subtle symptoms. As a result, they may delay coming into the hospital. But if women have STEMI heart attacks, they need immediate care just as men do.

    A statewide policy for STEMI?

    Elsewhere in the country, CODE STEMI systems, like the one implemented by UK HealthCare, are being utilized within health care systems, such as Mayo and Duke, and with their affiliates. CODE STEMI systems have yet to catch on as a state policy. There are many issues to consider: Which hospital should treat these patients? Should a patient be taken to a hospital that is different from the one where his or her cardiologist practices? Implementing a state policy is more complex than implementing a policy for a trauma system. Many smaller hospitals are equipped to provide care for patients with chest pain, so competition for these patients is intense.

    What we want to make sure of in Lexington is that we’re rapidly triaging and treating acute heart attacks of the STEMI variety. This is now a quality and safety issue for UK HealthCare.

    Dr. Campbell is director of the UK HealthCare Coronary Care Unit and associate professor of medicine in the UK College of Medicine.

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