YOU ARE HERE: LAT HomeCollections


Longer Ambulance Ride Could Save Lives

Heart-attack patients usually go to the nearest hospital, but experts say angioplasty is best.

October 12, 2003|Daniel Q. Haney | Associated Press Writer

WESTON, Fla. — Almost anywhere else, the ambulance crew would have gathered up Buddy LaRosa in mid-heart attack and raced to the closest emergency room.

They arrived that hot summer afternoon to find a classic cardiac emergency, the kind suffered by more than 1 million Americans a year. LaRosa had just climbed out of his pool from swimming laps, and he had an awful pain in his chest. His left arm was numb.

Soon the paramedics had a dozen electrocardiograph leads hooked to his chest. The spiky waves showed an ominous pattern. ST-segment elevation, they call it, the worst kind of heart attack.

Somewhere inside his heart, a blood clot had blocked one of the major arteries. Muscle downstream from it would starve and die unless something was done -- and fast.

So the usual practice of heading for the nearest medical facility -- in this case, a perfectly competent community hospital just five minutes from LaRosa's house -- would seem to make perfect sense. There, he would probably get a shot of a clot-dissolving drug, standard treatment since the mid-'80s.

But heart attack treatment has undergone a quiet revolution, one that ambulance services and small hospitals have largely ignored. Many heart specialists now agree that the clot-dissolving drugs are passe, or should be, and large hospitals have generally stopped using them. Instead, the best treatment is an emergency procedure called a primary angioplasty.

Even more reliably than clot drugs, it can stop a heart attack cold if done within the first two or three hours. But it is available only at major hospitals with top-tier cardiac centers.

So the little community hospital is no longer the ideal place to treat a heart attack, especially if it occurs within driving distance of an angioplasty center, as the vast majority do.

Nevertheless, specialists estimate that only about a third of heart attacks in the United States are treated with primary angioplasty. Most end up at hospitals that can't do them, and they aren't transferred to places that can.

So the most remarkable thing about LaRosa's otherwise run-of-the-mill heart attack in July was what happened after the medics loaded him into their big red ambulance. They raced right by the community hospital, then past another one, eating up 20 precious minutes to deliver LaRosa to Cleveland Clinic Florida, a new hospital in Fort Lauderdale's lush western suburbs. The medics transmitted LaRosa's EKG ahead, giving the four-member angioplasty team time to get ready.

Twenty minutes after they wheeled him through the ER doors, LaRosa was stretched out in the second-floor catheterization lab beneath a big overhead X-ray camera. The pictures showed his right coronary artery blocked. Quickly, Dr. Howard Bush pushed a wire through the clot, then briefly inflated a balloon.

The obstruction disappeared. The heart attack was over.

LaRosa's experience was unusual because the Broward County ambulance service is one of the nation's few with a policy of driving heart attack patients to medical centers that can do primary angioplasty.

"In our community, this system has worked," Bush said. "I know we are saving lives."

Elsewhere, though, patients typically get such treatment only if they end up at an angioplasty hospital by chance.

"It's really wrong what's going on," said Dr. Barry Kaplan, cath lab director at New York's Long Island Jewish Medical Center.

Evidence has been building since the late 1980s that angioplasty works better than clot drugs, and cardiologists seem to have agreed with that conclusion in the past five years.

"Every study that comes out shows that primary angioplasty is superior, almost without exception," said Dr. Gregg Stone, director of cardiovascular research at Lenox Hill Hospital in Manhattan.

Many specialists were skeptical when those studies began, said Dr. Cindy Grines of William Beaumont Hospital in suburban Detroit, who led some of the pioneering research.

But now there have been 23 such comparisons. Taken together, they suggest that about 9% of heart attack victims die after getting clot drugs, compared with 7% after primary angioplasty. The risk of recurring heart attacks drops in half, from 7% to 3%, and the risk of stroke -- the most serious complication of the clot drugs -- falls from 2% to 1%.

The goal of both treatments is to restore blood flow in the heart. Primary angioplasty does this in 95% of cases, while the clot drugs succeed in about two-thirds.

So if angioplasty's benefit is unquestioned, why do most victims still get a less effective treatment?

Doctors estimate that fewer than one in five hospitals can offer emergency angioplasty around-the-clock, and some people live too far away. However, about 80% of the population lives within an hour's drive of an angioplasty center.

Grines believes that the real reason has more to do with economics. "There is no incentive to change," she said. "The small hospitals don't want to divert patients to larger hospitals because that is lost revenue."

Los Angeles Times Articles