Cardiologist, South County Hospital
Wakefield, Rhode Island
As President of the American Heart Association (AHA) in Rhode Island, Dr. Fera is involved with the AHA's Mission: Lifeline. This national initiative focuses on improving the system of care for the deadliest types of heart attacks. Called ST-elevation myocardial infarctions or STEMIs (pronounced "stemmies"), these attacks affect a large portion of the heart. Dr. Fera explains how STEMIs are treated and what Mission: Lifeline is doing to help the nearly 400,000 people who suffer STEMIs each year.
Q: How has the care for heart attacks changed over the last few decades?
A: In the mid-1980s, the treatment for heart attacks was revolutionized with the advent of thrombolytic therapy, or clot-busters. These were given generally in an emergency room setting to dissolve the blood clot blocking the artery. If they were successful in opening the artery, blood flow would be restored to the heart muscle.
Over the next decade, a balloon/stent option evolved for patients with STEMIs—opening up the arteries with primary angioplasty. [The procedure is called primary angioplasty, rather than just angioplasty, when performed during a heart attack.] Initially it was done with just balloons. Now it's done with balloons followed by insertion of a stent, which provides more durable treatment.
The difference between clot-busters and primary angioplasty is that every emergency room in the country can deliver clot-busters. But what we found is that clot-busters worked maybe 80 percent of the time, and not all patients were good candidates. These drugs dissolve blood clots everywhere, so not surprisingly, one of the major complications is bleeding. Primary angioplasty, on the other hand, is virtually 100 percent successful. The problem is that most hospitals don't have the staff or the resources to perform angioplasties in patients having a STEMI. So while it's the treatment of choice, it's not the most available treatment.
Q: How is Mission: Lifeline helping patients get to the most appropriate hospital for treatment?
A: Traditionally, EMS [emergency medical services] brings patients to the nearest medical facility. But that might not be where primary angioplasty can be delivered. So part of Mission: Lifeline is to help EMS providers learn to recognize STEMIs so they can take patients to the appropriate hospital. In Rhode Island, patients can receive primary angioplasty at Rhode Island, Miriam, and Landmark Hospitals. Kent Hospital also plans to start offering primary angioplasty this year.
Most chest pain is not from a heart attack. However, the only way to really recognize a STEMI, whether you're an EMS person or a physician, is with a 12-lead electrocardiogram—a regular EKG. The problem with the 12-lead EKG is that not all trucks have the equipment because of limited funding, and not everybody knows how to use them because of training issues.
So part of the Heart Association's charge has been to encourage EMS training on 12-lead EKGs so patients are taken to the right hospital. If EMS is able to transmit the EKG to the hospital where a STEMI patient is being taken, the appropriate staff can be notified early to return to the hospital if it's after hours.
If there was going to be a long delay, or primary angioplasty is not available in the patient's area, EMS should take patients to the nearest hospital so they can get a clot-buster.
Q: What should patients do to make sure they get the best care for a heart attack?
A: One of the most important things is getting to the right hospital quickly and by rescue. Patients will sometimes wait at home, either in denial or because they attribute symptoms to less serious things like indigestion. And when they do decide to go, about 50 percent of people with STEMIs walk in to the emergency room. They think they can get to the hospital faster than the rescue, and maybe they can. But that doesn't mean you'll get treated earlier, or that you'll be at the right hospital.
Q: How can patients recognize a heart attack?
A: People sometimes feel that heart attacks have to have severe pain—the elephant sitting on my chest. And certainly many people who have STEMIs describe intense pressure or discomfort, but many times patients feel that the pain wasn't that bad. Maybe it's unfortunate that it doesn't hurt more because it would prompt people to take action.
Generally, patients should be alert to symptoms that don't go away. If you have a minute of chest pain, that's not a heart attack. But if someone has ongoing chest tightness, shortness of breath, tightness radiating in jaw or back or arm, nausea, cold sweats...if those last more than 10 or 15 minutes, clearly there's something serious going on, and I think they should err on the side of caution and call EMS.
What happens to your heart during a heart attack?
Essentially, there is either total or partial blockage of the artery, generally with both cholesterol plaque and blood clot. So the blood flow is interrupted to such a severe degree that unless the blood clot is removed or dissolved, there is permanent damage to the heart. The longer the artery is blocked, the more muscle is damaged. If the artery remains blocked long enough, for two or three hours, the damage to the heart muscle is essentially permanent. If the patient survives, the heart muscle will be replaced with scar tissue, and that scar tissue won't contribute to the pumping function of the heart. That's why the mantra in treating heart attacks is "time is muscle."
What kinds of warning signs might people have prior to a heart attack?
Symptoms that occur with exertion but go away with rest are very suspicious. One patient told me that he had indigestion every time he walked, and I said, "Well, there's no reason to get indigestion every time you walk. Does it go away every time you stop walking?" He said yes, and I said, "Well, that's not indigestion." He was diabetic, and he turned out to have severe coronary artery disease. His symptoms felt more like indigestion, but the context was very suspicious.
Editor's note: See the American Heart Association for more information on heart attack warning signs.
What role do family members play in helping patients who may be having a heart attack?
What we're doing at the Heart Association isn't just patient education—it's public education. So many times I say to male patients, "You know, your wife saved your life. She made you come to the emergency room." A lot of times it's a friend or family member who encouraged the patient to do the right thing. Patients don't want to go to the hospital. They say, "I don't have time for this today. I have too many things to do. If I go the emergency room, I'll be stuck there for hours." So sometimes the objectivity resides in the family member.
One in five patients with heart attacks still die. So it's not that the worst-case scenario is that you get treatment late and your muscle is weaker. The Mission: Lifeline Program saves muscle and improves prognosis, but primarily its goal is to save lives. The longer people wait, the higher the mortality.
Are you seeing fewer heart attacks because of improved care and better patient education? Or are you seeing more heart attacks because of obesity and sedentary behavior?
Well, we're seeing fewer heart attacks than we used to. I think that's primarily because of the aggressive treatment that's been going on, as well as programs that encourage people to quit smoking and be more active. The drugs to treat cholesterol, the statins, have changed the history of the disease. If you have coronary artery disease, there's no cure, but there is treatment.
However, we have a new generation of young people with obesity and early diabetes—and heart disease follows. It doesn't occur at the onset. We're concerned as cardiologists that this generation is going to grow up and start having heart attacks younger, so the improvement we've made over the last 20 years may be eroded as this generation's risk factors catch up with them.
For Rhode Islanders
How has the EMS system in Rhode Island changed because of Mission: Lifeline?
The Rhode Island Department of Health has provided a new protocol that allows EMS to take patients having STEMIs to Miriam, Rhode Island, or Landmark Hospital even when that is not the closest hospital. The challenge in Rhode Island is we have approximately 70 different EMS systems. Other places, like Boston, have one. So how do you get 70 different groups of EMS staff to be all on the same page?
Many EMS systems in the state are volunteer, and the budgets are not what they are elsewhere. And as with anything else, practice makes perfect. Providence, Cranston, and Warwick EMS have a lot of experience in taking care of heart attack patients, while smaller towns have less experience, as their calls are far and few between. Also, some towns' EMS, such as Bristol and South Kingstown, are all paramedics, which is the highest level of training. Other systems may have one or no paramedics.
The Heart Association held a training program at Crowne Plaza in Warwick to talk about these issues, to talk about changing the model and treatment paradigm. Over 200 people attended, and many were EMS staff. The Department of Health is also helping to support these kinds of training programs.
