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New Regional Initiative to Improve Care for Acute Heart Attack Patients

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Duke Health News 919-660-1306

DURHAM, N.C. -- Since rapidly re-opening the clogged
coronary arteries of patients with a heart attack can improve
their survival, a consortium of eight regional hospitals have
joined to ensure that these patients are quickly identified and
receive the most appropriate therapy available.

The group, organized by cardiologists at the Duke Clinical
Research Institute (DCRI), also plans to expand this pilot
project statewide within a year, in hopes that it can
eventually serve as a model for improving the care of acute
heart attack patients nationwide.

The key to the successful treatment of patients rushed to
emergency rooms with heart attack symptoms is to rapidly assess
and if necessary to open up the clogged coronary arteries that
caused the heart attack, or myocardial infarction (MI).

Physicians have two main approaches to open arteries and to
reperfuse starving heart muscle with blood -- clot-busting
drugs known as thrombolytics or a procedure known as
angioplasty. While thrombolytics can be administered in almost
every facility fairly quickly, they do have side effects -- the
major one being bleeding. Angioplasty has been proven to be
slightly more effective than thrombolytics when the procedure
is performed within 90 minutes of symptom onset, said the
researchers.

Developing systems to rapidly treat heart attack patients is
especially important for North Carolina, the Duke cardiologists
said, because data from a recent nationwide registry of heart
attack patients showed that only 64 percent of North
Carolinians who could have benefited from reperfusion therapy
actually received it. This compares to a national rate of more
than 70 percent.

"We want to find ways to help hospitals eliminate the
barriers within their systems that prevent the optimal number
of eligible MI patients from receiving reperfusion therapy,"
said Mat Lotfi, M.D., a DCRI researcher and the principle
investigator of the pilot project, which has been dubbed RACE
-- Reperfusion of Acute MI in Carolina Emergency
Departments.

"Treating eligible patients who would otherwise not receive
any type of reperfusion therapy is believed to be one of the
most important avenues for decreasing death rates for patients
coming to emergency departments with a heart attack," Lotfi
continued. "It has been estimated that more than 10,000 lives
could be saved each year if these eligible patients received
therapy."

The key component of the pilot project is to help hospitals
and clinics better understand why eligible patients might not
be identified as soon as possible, so the appropriate care can
be given.

In some cases improving effectiveness can require only
locating an electrocardiogram machine (EKG) in emergency rooms.
In other cases, an improvement could involve better
coordination between emergency room physicians with
cardiologists and emergency medical services (EMS)
transportation officials. Other ways the RACE program plans to
improve outcomes of MI patients include funding educational
nursing programs, conducting physician teleconferencing
seminars on reperfusion therapy, and providing emergency room
guideline tools.

For Kimmie Yarborough, M.D., emergency room physician at
Person Memorial Hospital in Roxboro, this timely attention to
coordination of efforts is paying dividends. Like many smaller
hospitals in rural settings, Person Memorial does not yet have
a catheterization laboratory to perform angioplasties.

"Working with Duke and Person County EMS, we can determine
within ten minutes of arrival whether or not the patient should
be transferred to Duke for an angioplasty or stay with us and
receive thrombolytics," Yarborough said. "We've already
transferred three patients to Duke this way, and they've done
extremely well."

To make this transfer procedure successful, Yarborough or
her colleagues can call a 24/7 toll-free hotline to Duke, where
they can conduct a consultation with Duke cardiologists, as
well as with the EMS team, within a matter of minutes. Patients
deemed to be candidates for angioplasty never leave the EMS
stretcher and are transported directly to Duke, where a
catheterization lab is staffed and waiting. Emergency
physicians also can call the number if they have questions or
concerns about a specific reperfusion strategy.

"This is a great way for us to take the best possible care
of patients coming to our emergency department with an acute
MI," Yarborough continued. "While we may see only 12 to 15 such
patients each year, when you add up all the hospitals in the
state, projects like this can go a long way toward saving lives
in North Carolina."

According to Mark Bernat, M.D., emergency room physician at
Nash Health Care System in Rocky Mount, about five patients who
could potentially benefit from the RACE program come to his
facility each month.

"We already take excellent care of MI patients, so the RACE
project is allowing us to tweak our systems to be even better,"
Bernat said. "We are focusing on nursing education, and since
most of our ambulances have EKG capabilities, we're also
working on improving communication between the doctors and the
paramedics to better identify those patients who could benefit
from reperfusion therapy before they arrive at the emergency
department.

"With this early identification, we know how to be prepared
to treat patients when they arrive, or possibly transfer them
for a cardiac catheterization at another facility," he
continued.

Nash has a catheterization laboratory, but it is used only
for diagnostic purposes, and not interventions. Patients
requiring interventional catheterization are transferred to
either Wake Medical Center in Raleigh or Greenville-Pitt
Memorial Hospital in Greenville.

As the project continues, the team will collect data on how
each of these "eligible but untreated" patients fared, with the
goal of providing feedback to each facility on how to
streamline the process of evaluating and treating patients

"Unlike some national efforts that attempt to deal with this
issue from afar, we are actually in the trenches trying figure
out what works the best," said Duke cardiologist James Jollis,
M.D., who along with Christopher Granger, M.D., constitute the
Duke portion of the team. "Much time has been spent over the
years conducting clinical trials to figure out what works the
for heart attack patients.

"Now, we are trying to put into practice what we all know --
opening arteries quickly saves lives," Jollis continued. "We've
hit a wall at treating about 60 percent of eligible patients
and we're not improving much more -- we believe we can do
better."

Other RACE members are Alamance Regional Medical Center;
Durham Regional Hospital; Maria Parham Hospital, Sampson
Regional Medical Center; and Southeastern Regional Medical
Center.

The Duke cardiologists plan to join with the North Carolina
chapter of the American College of Cardiology (ACC) to expand
the project statewide, probably some time later next year.
Preliminary results will be presented at the North
Carolina/South Carolina ACC meeting on Oct. 5, 2003 in
Charlotte, NC.

RACE is funded by a two-year, $160,000 unrestricted
educational grant from Genentech Corp., South San Francisco,
Calif. Genentech manufactures t-PA, one thrombolytic agent used
to open clogged arteries.

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