Heart attacks occur when the blood supply to the heart muscle is compromised or completely obstructed, usually by a thrombus in the coronary arteries. Heart attacks are included in the spectrum of medical disorders termed acute coronary syndromes (ACS). Acute coronary syndromes include ST elevation myocardial infarctions (STEMI), Non ST elevation myocardial infarctions (NSTEMI), and unstable angina. An electrocardiogram (ECG) is used to differentiate the different types of acute coronary syndromes. If the ECG shows an ST segment that is elevated (STEMI), it suggests that there is a complete block of a coronary artery and a transmural infarction of the myocardium has occurred. This finding is informally termed “Tombstoning” or “The Widow Maker”. If the ECG shows an ST segment that is depressed (NSTEMI), it suggests that there is a non-occlusive or partial blockage of a coronary artery. Treatment for these conditions differs. NSTEMI and unstable angina are treated medically with aspirin, beta blockers, statins, anticoagulants, and anitplatelets. STEMI is treated with 1) thrombolytics, such as Streptokinase, to cause lysis of the occlusive thrombus or 2) percutaneous coronary intervention (PCI) with primary coronary angioplasty to mechanically alleviate the occlusive lesion usually followed with stent deployment. The American College of Cardiology has established guidelines that recommend a door-to-needle (D2N) thrombolytic administration time of 30 minutes, and a door-to-balloon (D2B) PCI time of 90 minutes. When it comes to heart attacks, time is equal to heart muscle and longer time to treatment causes more heart damage. Researchers, lead by Dr. Harlan Krumholz, have shown that the D2B time for patients having STEMI has dramatically been reduced over the last five years in the United States. The research findings were published online ahead of print in the journal Circulation. The researchers evaluated data collected by the Centers for Medicare and Medicaid Services (CMS) from over 300,000 patients requiring primary coronary angioplasty between 2005 and 2010. The results revealed that 91% of patients were treated with a D2B time of less than 90 minutes in 2010 compared to 44% in 2005. In addition, over 70% of patients were treated with a D2B time of less than 75 minutes in 2010 compared to only 27% in 2005. The median D2B time was improved from 96 minutes in 2005 to 64 minutes in 2010. The authors wrote, “We document remarkable improvement in D2B times from 2005 through 2010. The improvement demonstrates the results that can be produced by collaboration among healthcare professionals, hospitals, federal research agencies, and national organizations interested in patient care toward the achievement of a shared goal”. These results were likely obtained through several methods including publications identifying strategies for improvement, national improvement initiatives, coordination of care, and an emphasis on quality improvement. This is an extraordinary achievement and our healthcare system should be applauded for the improvement.
Listen to the Medpage Today interview with Dr. Harlan Krumholz below:
Harlan M. Krumholz et al. “Improvements in Door-to-Balloon Time in the United States, 2005 to 2010” Circulation published online ahead of print August 22, 2011 doi: 10.1161/CIRCULATIONAHA.111.044107