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January 10, 2008

RACE to stay alive - Program increases chances of survival for heart attack victims

Editor’s Note: This is the first in a series of articles detailing clinical areas which received five-star ratings by HealthGrades, the nation’s leading independent healthcare ratings company.

When a person is experiencing a heart attack, reopening blocked arteries is the best way to save their life.

Haywood Regional Medical Center and other area hospitals throughout Western North Carolina are improving patients’ chances of surviving a heart attack with the help of a statewide program called RACE.

RACE, which stands for Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments, is a program that coordinates the efforts of ambulances, emergency departments and hospitals to reduce the amount of time it takes for heart attack patients to receive lifesaving treatment.

Research has found that the chances of surviving a heart attack increase significantly when patients receive either a clot-busting drug administered within 30 minutes of hospital arrival, or angioplasty surgery that uses a small balloon to open blocked arteries administered within 90 minutes of the heart attack.

By quickly unblocking clogged arteries, these treatments save lives by keeping the heart from sustaining irreparable damage due to a prolonged lack of oxygen.

A standard protocol has been prepared to organize emergency responders, emergency departments and hospitals to provide the best treatment of heart attacks. Since its inception in January 2006, more than 70 percent of patients at angioplasty centers throughout the state received angioplasty within the recommended 90 minutes of arriving at the hospital, which is a 20 percent improvement.

“Our goal is to have a patient in the cath lab to open up the blockage within 90 minutes from the time they come in,” said Eddie Brown, Emergency Department Director at Haywood Regional Medical Center.

“Our first step is to administer an EKG (electrocardiogram) immediately after it has been identified that a patient is suffering with a heart attack,” Brown said. “We can start initial treatment as arrangements are being made to have a helicopter transport them to Mission.

“The key is to seek treatment immediately if you are experiencing symptoms of a heart attack. The faster steps are taken, the better someone’s chances of survival are,” he said.

When EMS responds to a patient with a complaint of chest pain, they administer four baby aspirins and sublingual nitroglycerin, if the patient's blood pressure will tolerate it, said Dr. David Peterson, staff cardiologist for Haywood Regional Medical Center. Dr. Glenn Harris is also a staff cardiologist at Western Carolina Cardiology.

“They place the patient on oxygen and obtain a 12-lead ECG. If the patient's ECG identifies them as a candidate for the RACE trial, the ED is notified by radio,” Peterson said. “In early 2008, the ECG itself will be transmitted via cell phone.

Patients identified in the eastern part of the county will, in most cases, be directly transferred to Mission Hospital for catheter-based intervention (i.e. stent or balloon angioplasty).”

Patients near the hospital or the western part of the county will stop at HRMC for stabilization and initiation of further medical therapy, to include a blood thinner called heparin, a beta-blocker called metoprolol to slow the patient's heart rate, and another blood thinner called integralin. Patients spend no more than 20 to 30 minutes in the Emergency Department before the same EMS crew transports them to Mission for catheter-based intervention.

If a patient comes via private vehicle and complains of chest pain, an ECG is attempted to be obtained within 10 minutes, and the same therapy is administered if appropriate.

“I think it is an extremely valuable program. The coordination between our EMS, emergency department, and Mission Hospital has been outstanding. Our time from patient presentation to “vessel opened” has generally been less than two hours. Our overall goal is less than 90 minutes for everyone,” Peterson said.

“Multiple studies have suggested the advantage of catheter-based intervention over the use of ‘clot-busting’ medicines, and this program is one way to offer our patients cutting-edge therapy for their myocardial infarction,” he said.

The RACE program is coordinated through Duke University and is sponsored by the American College of Cardiology. Sixty-eight hospitals in five regions (Greenville, Chapel Hill/Durham, Greensboro/Winston-Salem, Charlotte and Asheville) participate in the RACE program.

Regional hospitals that participate in the program include Haywood Regional Medical Center, Mission Hospitals, Angel Medical Center, Highlands-Cashier Hospital, The McDowell Hospital, Murphy Medical Center, Pardee, Park Ridge, Rutherford, Blue Ridge Regional Hospital, St. Luke’s Hospital, Transylvania Community Hospital and WestCare.

Other RACE partners include the Duke University Medical Center Clinical Research Institute and the N.C. chapter of the American College of Cardiology. Blue Cross/ Blue Shield of North Carolina also supports the program with a $1 million corporate grant.

During the two-year pilot project, RACE researchers will collect data on heart attack patients who receive treatment, as well as those who did not receive it. The project will also help uncover duplication and unnecessary steps that add to the time between a patient’s arrival at an emergency department and treatment.

RACE organizers also plan to fund educational nursing programs, conduct physician seminars on reperfusion therapies, provide emergency room guidelines and expand the use of EKG machines in ambulances so vital data on patients’ hearts can be transmitted ahead to emergency personnel.

Organizers also have established a 24-hour hotline led by senior cardiologists who can consult with emergency room physicians at smaller hospitals lacking an on-site cardiologist who is available 24 hours a day.

“Dr. Harris and I are always available 24/7 for any cardiac-related illnesses,” Peterson said. “With the initiation of the RACE trial, the number of patients we see in the emergency room for acute myocardial infarction has clearly decreased.

“If the patient is unstable, we will often see them in the emergency room for stabilization and subsequent transfer. If they remain stable on medications, we are generally not called, in order to save time in the whole transfer process, as we have always been taught ‘time is heart muscle.’

“Our practice is always available for patient follow-up after their initial hospitalization at Mission Hospital. The patients are entered into cardiac rehabilitation, with close follow-up with both their primary physician and cardiologist,” Peterson said.

Haywood Regional Medical Center received five-star ratings by HealthGrades in the treatment of the following conditions: heart attack, atrial fibrillation, heart failure, bowel obstruction, respiratory failure, gastrointestinal surgeries and procedures, GI bleed, pneumonia, COPD and sepsis.

“By collaborating with our physicians, EMS and other regional healthcare institutions, we will continue to sustain positive patient outcomes,” Peterson said.

Recommendations for the RACE program are based upon established guidelines, published data, and the knowledge and experience of numerous individuals specializing in acute myocardial infarction care.

Haywood Regional Medical Center was established in 1927 as the first county hospital in North Carolina. The current facility opened in 1979. HRMC is the third largest employer in Haywood County,

Symptoms of a heart attack

A heart attack (also known as a myocardial infarction) is the death of heart muscle from the sudden blockage of a coronary artery by a blood clot. Although chest pain or pressure is the most common symptom of a heart attack, heart attack victims may experience a diversity of symptoms that include:

•Pain, fullness, and/or squeezing sensation of the chest •Jaw pain, toothache, headache •Shortness of breath •Nausea, vomiting, and/or general upper middle abdomen discomfort •Sweating •Heartburn and/or indigestion •Arm pain (more commonly the left arm, but may be either arm) •Upper back pain •General malaise (vague feeling of illness)

Early reopening of blocked coronary arteries reduces the amount of damage to the heart and improves the prognosis for a heart attack. Medical treatment for heart attacks may include anti–platelet, anti–coagulant, and clot dissolving drugs as well as angiotensin converting enzyme (ACE) inhibitors, beta blockers and oxygen.

Patients suffering a heart attack are hospitalized for several days to detect heart rhythm disturbances, shortness of breath and chest pain.

Further heart attacks can be prevented by aspirin, beta blockers, ACE inhibitors, discontinuing smoking, weight reduction, exercise, good control of blood pressure and diabetes, following a low cholesterol and low saturated fat diet that is high in omega 3 fatty acids, taking multivitamins with an increased amount of folic acid, decreasing LDL cholesterol, and increasing HDL cholesterol.