Coordinated Emergency Care Saves Lives, Lessens Damage During Heart Attack
DURHAM, N.C. -- Patients suffering from deadly heart attacks can be spared more extensive heart damage when emergency responders and hospitals work together to standardize their treatment processes, according to a study published August 1 in Circulation, a journal of the American Heart Association (AHA).
The findings are based on a national study launched in 2012 by the AHA and Duke Health that focused on ST-segment elevation myocardial infarction (STEMI), a type of heart attack where one of the blood vessels supplying the heart becomes blocked. Without blood flow, the heart muscle can be quickly and irreparably damaged, leading to shock, cardiac arrest and death.
“This work is important because heart attacks are such a common cause of death,” said Christopher Granger, M.D., senior author of the study who helped lead the national project.
“The single most important way to prevent death in the case of heart attack is to rapidly open the blood vessel so that blood flow is restored. This is one of the most important things we can do in all of cardiovascular care,” said Granger, who is also a professor of medicine at Duke University School of Medicine.
The 18-month project, called Mission: Lifeline STEMI Systems Accelerator, involved nearly 24,000 patients, 484 hospitals, and 1,253 EMS agencies in 16 regions across the U.S., including large, populated cities such as New York City, Atlanta, and Houston.
Current national guidelines for STEMI treatment have two key recommendations for how quickly the blood vessel should be opened.
For patients who initially arrive at a hospital that is fully equipped to respond to STEMI, the unblocking should happen within 90 minutes of first contact with emergency responders. For patients who must be transferred to facilities that can fully handle their cases, the unblocking should happen within 120 minutes of first medical contact.
Patients treated within the guidelines have higher survival rates. But according to the study, up to 50 percent of patients in the U.S. currently aren’t treated within the recommended times, as coordination is often lacking among those who care for STEMI patients before and after arrival at the hospital.
"People are dying with ST-segment elevation myocardial infarction because of gaps in the American healthcare system: gaps between competing hospitals, gaps between competing physician groups, and gaps in emergency medical services,” said James Jollis, M.D., a study co-author, project leader, and adjunct faculty at Duke University School of Medicine,
With coordinated efforts over the course of this study, however, researchers saw a modest yet statistically significant increase in the proportion of patients meeting the guideline goals:
• In patients transported by EMS to hospitals fully-capable of treating them, the proportion increased to 55 percent from 50 percent.
• In patients transferred from other facilities, the proportion increased to 48 percent from 44 percent.
Additionally, five of the 16 regions that stood out as the most improved saw an increase to 57 percent from 45 percent in the proportion of their patients meeting the 90-minute guideline when transported by EMS. The most successful region treated 76 percent of its patients within guideline goals by the end of the project.
The work highlights the crucial collaboration between paramedics, emergency physicians and nurses, interventional cardiologists, and hospital administrators. The results also confirm the importance of better training, feedback for hospitals and EMS agencies, and coordinated and standardized STEMI treatment protocols. For example, Granger said in many of the regions, emergency responders were given standardized protocols for diagnosing patients with STEMI symptoms and activating teams to be ready when patients arrived at the hospital, regardless of the hospital where the patient was being taken.
“For the first time in many of these regions, this project has provided a framework for bringing together groups that are critically important to providing the best emergency care,” Granger said. “Even though the effect was modest overall, we proved that it is possible to significantly change care and if these results are leveraged and optimized over years of effort, there could be even more benefit.”
“Our results demonstrate a successful approach to bridging these gaps that appears to be translating into saving lives,” Jollis added.
In addition to Granger and Jollis, study authors include Hussein R. Al-Khalidi; Mayme L. Roettig; Peter B. Berger; Claire C. Corbett; Harold L. Dauerman; Christopher B. Fordyce; Kathleen Fox; J. Lee Garvey; Tammy Gregory; Timothy D. Henry; Ivan C. Rokos; Matthew W. Sherwood; Robert E. Suter; and B. Hadley Wilson.
The Medicines Company, AstraZeneca, Philips Healthcare, and Abiomed provided funding for the study through research and educational grants. The authors’ disclosures are available in the study’s manuscript.