Shrinking Door-to-Balloon Time in Myocardial Infarction 心肌梗塞

choi

Gina Kolata, Racing the Clock, Saving the Heart; Faster care helps death rate plunge 38% in decade. New York Times, June 21, 2015 (front page; in the Series “Mending Hearts,” with subtitle “A push for speed”).
www.nytimes.com/2015/06/21/healt ... k-victims-stat.html

Quote:

"With no new medical discoveries, no new technologies, no payment incentives — and little public notice — hospitals in recent years have slashed the time it takes to clear a blockage in a patient’s arteries and get blood flowing again to the heart.  The changes have been driven by a detailed analysis of the holdups in treating patients and a nationwide campaign led by the American College of Cardiology, a professional society for specialists in heart disease, and the American Heart Association.

"From 2003 to 2013, the death rate from coronary heart disease fell about 38 percent, according to the American Heart Association * * * The National Heart, Lung and Blood Institute, the primary federal agency that funds heart research, says this decline has been spurred by better control of cholesterol and blood pressure, reduced smoking rates, improved medical treatments — and faster care of people in the throes of a heart attack. * * * coronary heart disease [the leading cause of death in US], which accounts for one of every seven deaths in the United States or 375,000 a year.

"Now, nearly all hospitals treat at least half their patients in 61 minutes or less * * * In 2007, the first year of a national campaign to speed treatment

“"The heart story began nearly a decade ago when Dr [Harlan M] Krumholz, the Yale cardiologist, had an idea.  Medicare had created a national database showing how long it took hospitals across the country to get heart patients’ arteries opened. It was a bell curve year after year * * * Dr. Krumholz and his colleagues visited the 11 best performing hospitals. They were not famous institutions or major medical centers, said Elizabeth Bradley, a professor of public health at Yale and a leader in the project. Some were community hospitals; others were far from major population centers. * * * Dr Krumholz and his colleagues persuaded The New England Journal of Medicine to publish their already accepted paper in the same week at the end of November 2006 that the American College of Cardiology announced a national campaign to get hospitals to change their ways.

Note:
(a) Our Lady of Lourdes Medical Center in Camden, New Jersey
(i) Our Lady of Lourdes Medical Center was founded in 1950 by Franciscan Sisters of Allegany, New York.
en.wikipedia.org/wiki/Allegany_(town),_New_York
(The origin of the name Allegany is uncertain)
(A) Not to be confused with Allegheny River and Mountains of Pennsylvania.
(B) Lourdes is a town in France, noted for apparitions of the Heavenly Mother in 1858.
(ii) "Located directly across the Delaware River from Philadelphia," City of Camden, New Jersey is the county seat of Camden County. "The county was named for Charles Pratt [1714 – 1794], 1st Earl Camden, a British judge, civil libertarian, and defender of the American cause."

b) "The improvements in treatment have spilled over into the care of stroke victims. Neurologists watched with envy as cardiologists slashed their times. For strokes, too, the time it takes to be treated with the clot-dissolving drug tPA is of the essence. 'Time is brain,' neurologists say. They began to copy the cardiologists. * * * The payoff from the changes has been breathtaking, experts say. 'Heart disease mortality is dropping like a stone. This is a reason why,' said Dr Eric Peterson, a cardiology researcher at Duke. 'And stroke has fallen to fifth as a major killer. This is a reason why.' "
(i) tPA = tissue plasminogen activator, which cells secreted.
(A) For its (tPA’s) mechanism, see the cartoon in Figure 1 of
Collen D and Lijnen HR, The Tissue-Type Plasminogen Activator Story. Arteriosclerosis, Thrombosis, and Vascular Biology, 29: 1151-1155 (2009).
atvb.ahajournals.org/content/29/8/1151.full
(B) Widimsky P, Coram R, and Abou-Chebl A, Reperfusion Therapy of Acute Ischaemic Stroke and Acute Myocardial Infarction: Similarities and Differences. European Heart Journal, 35:147-55 (2014; review)
www.ncbi.nlm.nih.gov/pubmed/24096325
(abstract: “direct mechanical recanalization without thrombolysis is proven (myocardial infarction) or promising (stroke) to be superior to thrombolysis-but only when started with no or minimal delay
(ii) Coronary heart disease is treated with stent/balloon, not with tPA. Most arteries in brain is too small in diameter for a catheter to reach (and then put a stent).

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(c) "Most Camden residents having a heart attack are rushed to Lourdes, a medium-size Roman Catholic hospital founded in 1950 by the Franciscan Sisters of Allegany to serve the poor. It looks like a bisque-colored wedding cake perched high on a hill, with a statue of the Virgin Mary on top, hands folded in prayer."

bisque (food)
en.wikipedia.org/wiki/Bisque_(food)
(i) It is a French word.
(ii) The color in the Wiki page ("tomato pumpkin bisque") is typical of bisques in general.

(d) "They decided to have paramedics do an electrocardiogram, which can show the characteristic electrical pattern of the heart that signals a heart attack, as soon as they reached the patient and transmit it directly to the emergency room. That meant the staff could spring into action the moment the ambulance pulled in. The hospital designated a beige phone on a counter in the ER for calls from paramedics.”

ST elevation
en.wikipedia.org/wiki/ST_elevation
(the ST segment [situated between S and T] is abnormally high above the baseline)
(e) Before, "the ER doctor would fax an electrocardiogram to him [a cardiologist] him. ‘Yeah, it’s a Stemi [ST segment elevation myocardial infarction],’ he would say, using the acronym for a heart attack. ;Let’s call the interventionalist [or interventional cardiologist; not all cardiologist do angioplasty, which consists of catheter, balloon and /or stent].’

(f) “But then a debate arose.  A paper by Dr [Eric D] Peterson, the Duke cardiologist, and his colleagues, published in The New England Journal of Medicine in 2013, said that even though times had plummeted, the death rates for heart attack patients whose arteries were opened with balloons and stents had not budged. Could it be that faster just seemed better but that it actually made no difference to patient outcomes?  ‘That was demoralizing,’ Dr Krumholz said. But he did an analysis that found that the universe of heart attack patients being treated with stents and balloons had changed markedly. It used to be just the younger and healthier people who were more likely to have their arteries opened. Now, as the procedure became more popular and so many more people were treated this way, the group included more older and sicker people.  Dr Peterson concluded that analyses like his and Dr. Krumholz’s had challenges. The problem, he said, is that it is hard to accurately compare treatments given at different points. Nonetheless, the consensus — which he shares with Dr. Krumholz and other leading cardiologists — is that the shorter times and improved medical care contributed to the declining death rates and better outcomes for heart attack patients.”
(i) The 2013 paper:

Menees DS et al, Door-to-Balloon Time and Mortality among Patients Undergoing Primary PCI. New England Journal of Medicine, 369: 901-909 (2013)
www.nejm.org/doi/full/10.1056/NEJMoa1208200
(“in-hospital mortality (defined as the rate of death from any cause)”)

The study only looked into the mortality rate while patients were in hospital (lasting days)--rather than, say, one or five years later. The subtitle of the NYT report attests to the long-term success of angioplasty (though there is no journal article on this since 2013 -- a clinical trial takes time).