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Faster heart care: How one state did it

 

By MARILYNN MARCHIONE, AP Medical Writer 2 hours, 7 minutes ago

 

 

 

ORLANDO, Fla. - In an ideal world, every heart attack would end like Willard

" Ziggy " Hill's. Within 90 minutes of arriving at a small community hospital in

North Carolina, he was having a blocked artery reopened at Duke University

Medical Center 25 miles away.

 

" It was like being a car in a pit stop at NASCAR, " he said. " I thought 'I am

in really good hands.' "

 

Two years ago, he might not have been. North Carolina was a bad place to have

a heart attack, scoring below national norms of fast care. Now it may be one of

the best.

 

The reason is the nation's most ambitious statewide project to redo how

serious heart attacks are handled. Paramedics, doctors and 65 hospitals put

aside powerful individual interests like money and control, and focused on

giving faster care.

 

Why is this important? Drugs, devices and doctors do no good if they do not

reach people quickly, before the heart suffers permanent damage.

 

Heart attacks happen when arteries are blocked, crimping a critical blood

supply. The first choice of treatment is angioplasty, in which a tiny balloon is

pushed into the vessel and inflated to flatten the clog.

 

However, many small hospitals lack specialized suites called catheterization

labs needed for angioplasties. Instead, they sometimes give clot-dissolving

drugs, which do not always work.

 

In the North Carolina project, 55 small hospitals agreed to send appropriate

patients to 10 larger ones for angioplasty, even though it meant giving up

thousands of dollars of revenue.

 

" If this is your Aunt Bess and she comes in to your emergency department and

you offer her a level of care that's not the best, and you have to go to that

funeral in that small community, that's what they think about — not cost, " said

Mayme Roettig, the nurse who coordinated the project.

 

Big hospitals also had room to improve, too, said Dr. Christopher Granger, the

Duke cardiologist who led the project.

 

Statewide, " up to 40 percent who should get clot-busting drugs or angioplasty

were not getting it, and when it was being given it was being given too slowly, "

he said.

 

He reported one-year results of the project Sunday at an American Heart

Association meeting in Florida. They also were published online by the Journal

of the American Medical Association.

 

Researchers compared the care of more than 2,000 patients before and after the

project and found:

 

_More patients got care at top-tier heart hospitals, and more quickly than

similar patients did before the project began. Helicopter transfers rose, and

more paramedics diagnosed heart attacks from EKGs done in ambulances.

 

_The number of patients receiving angioplasty rose, and the portion of

eligible patients not receiving artery-opening procedures dropped.

 

_Every single measure of time improved. Examples: the average time it took a

small hospital to evaluate and refer patients to a larger one dropped from two

hours to 71 minutes; average transfer times plunged more than half an hour.

 

" They did a magnificent job, " said Dr. Harlan Krumholz, a Yale University

cardiologist who is leading a national campaign to speed up heart attack care.

 

" This is a great example of where people in a state got together and said

'Gee, if I were a patient, what's the kind of care that I would want, and how

can we deliver that?' " The stories from North Carolina are dramatic.

Paramedics like 26-year-old Joshua Codispoti in rural Person County made

judgment calls previously left to cardiologists. Last spring, he did an EKG in

an ambulance, diagnosed a heart attack in a healthy-looking man in his 30s, and

called a hotline to summon a team of specialists and ready a $2 million cath lab

(Duke has eight) for angioplasty. The team must be in the lab within 30

minutes, and the large hospitals must agree to take heart attack patients

regardless of whether they have an open bed, said Duke cardiologist Dr. James

Jollis. Codispoti's patient was quickly evaluated at 50-bed Person Memorial

Hospital and sent on to Duke. " I don't feel like we're giving up anything " by

referring people for advanced care, said emergency

room physician Dr. Kimberly Yarborough. She hasn't given clot-dissolving

drugs to a heart attack patient in nearly two years, since the project started.

Neighboring states also have benefited. Howard Campbell, 65, suffered a heart

attack in May at his Lake Gaston home just across the Virginia-North Carolina

state line. " I was on my rec room floor having a heart attack at 1:30, and

at 2:20 I was on a helicopter to Duke, " he said. When his wife arrived at

3:30, his procedure was already done. " It was like we had rehearsed it — it

just went so smoothly. " Campbell said. The project was funded by the

hospitals, Blue Cross and Blue Shield of North Carolina, and the Doris Duke

Foundation, which helped equip ambulances with EKGs. Doctors hope to expand it

to the 35 state hospitals not currently participating. Meanwhile, nearly

1,000 hospitals have joined a nationwide campaign that began a year ago to have

hospitals give angioplasty treatment faster.

Less than a third of patients get it within the recommended 90 minutes of

arrival, and the risk of dying goes up 42 percent if care is delayed even half

an hour longer. " This has been a pretty spectacular effort, " Krumholz said.

" If you can get people in really quickly, you can almost abort the heart attack.

It's such a different mindset than a few years ago when everybody said 'we're

busy, we're doing the best we can.' " Doctors will report first-year results

early next year. ___ On the Net: Heart Association:

http://www.americanheart.org/ JAMA: http://jama.ama-assn.org/ Hospital

ratings: http://www.hospitalcompare.hhs.gov/

 

http://news./s/ap/20071104/ap_on_he_me/faster_heart_care

 

----------

 

Study: New heart pill may rival Plavix

 

By MARILYNN MARCHIONE, AP Medical Writer 1 hour, 28 minutes ago

 

 

 

ORLANDO, Fla. - A new blood thinner proved better than Plavix, one of the

world's top-selling drugs, at preventing heart problems after procedures to open

clogged arteries, doctors reported Sunday. But the new drug also raised the risk

of serious bleeding. People given the experimental drug, prasugrel, were

nearly 20 percent less likely to suffer one of the problems in a combined

measure — heart attack, stroke or heart-related death — than those given Plavix,

a drug that millions of Americans take to prevent blood clots that cause these

events.

 

However, for each heart-related death that prasugrel (PRASS-uh-grell)

prevented, compared to Plavix, almost one additional bleeding death occurred.

 

" There is a price to pay " for greater effectiveness, Dr. Deepak Bhatt, a

Cleveland Clinic cardiologist, wrote in an editorial accompanying the results,

which were published online by The New England Journal of Medicine and presented

at an American Heart Association conference in Florida.

 

Still, many doctors said that on balance, the new drug comes out ahead, and

offers great promise as a more potent alternative to Plavix, which costs $4 a

day and does not work for many patients.

 

" I'm encouraged by the results " and think prasugrel should win Food and Drug

Administration approval because it so dramatically cuts non-fatal heart attacks,

said the Cleveland Clinic's Dr. Steven Nissen, a frequent government adviser.

 

Doctors can sort out who might most benefit from it, such as diabetics, and

who might face too much bleeding risk to use it, like the elderly, people who

previously had strokes and those with kidney problems, he said. (The Cleveland

doctors give to charity or the clinic the consulting and research fees they earn

from drugmakers.)

 

Doctors also were waiting for prasugrel's makers to clarify why they stopped

two small studies of it a week ago. They said it was due to dosing problems but

did not explain.

 

Prasugrel is being developed by Indianapolis-based Eli Lilly and Co. and a

Japanese firm, Daiichi Sankyo Co. It could be a hugely important drug, and the

study has been one of the most-watched tests of a novel heart medication in

recent years.

 

Like Plavix, prasugrel prevents blood components called platelets from

sticking together and forming a clot. Anti-platelet drugs are advised for most

people with stents — tiny mesh tubes that keep arteries open after balloon

angioplasty, an artery-clearing procedure that more than a million Americans

have each year.

 

Plavix, sold by Sanofi-Aventis SA and Bristol-Myers Squibb Co., has been the

most effective drug of this type. More than 70 million people have taken it

since it went on sale a decade ago.

 

Plavix had 18.6 million prescriptions and nearly $3 billion in U.S. sales last

year, according to IMS Health, a healthcare information firm. Worldwide sales

were nearly $6 billion.

 

The study comparing it to prasugrel involved 13,608 patients from 30 countries

and was led by Dr. Elliott Antman at Harvard Medical School and Brigham and

Women's Hospital in Boston. Prasugrel's makers paid for the study; many of the

researchers work or consult for them.

 

Study participants were having angioplasty due to heart attacks or blockages

causing sudden or worsening chest pain, and were randomly assigned to one drug

or the other for six to 15 months.

 

The results: about 12 percent of people taking Plavix but only 10 percent on

prasugrel suffered heart attacks, strokes or heart-related deaths — a 20 percent

reduction in risk. Only 1.1 percent on the new drug developed blood clots in

stents versus 2.4 percent on Plavix — a 52 percent lower risk. Prasugrel also

worked faster than Plavix and showed more effectiveness at the first checkpoint

— three days.

 

However, major bleeding occurred in 2.4 percent of those on prasugrel versus

1.8 percent of those on Plavix. This included brain or gastrointestinal

bleeding, or after falls. Fatal bleeding was uncommon, but four times more

frequent with the new drug.

 

Results hinted that some people might be in greater danger — those who had a

previous stroke, were elderly, or weighed less than 132 pounds.

 

These signs are why prasugrel's makers suspended two small studies a week ago

to see whether such patients should be included in the study or should get a

lower dose, said Dr. Anthony Ware of Eli Lilly. " It was a precaution ...

because of a risk of a safety problem rather than an actual one, " he said.

Lilly will conduct another big study of prasugrel in people not having

angioplasty but on medications because they are at risk of having a heart

attack, Ware said. That 10,000-person study will be led by Dr. E. Magnus

Ohman at Duke University Medical Center. In the study reported on Sunday,

" the benefit clearly outweighs the risk " for most patients, Ohman said.

Bhatt of Cleveland Clinic noted that even aspirin — which is widely recommended

to prevent clots and was prescribed to all patients in this study — carries a

risk of bleeding. Dr. Spencer King, a heart specialist at Piedmont Hospital

in Atlanta and spokesman for the American College of

Cardiology, was on the safety monitoring committee for the study. He said

prasugrel would be " a little bit of a tough sell " to doctors who are comfortable

with using Plavix, but that competition could give patients drugs more closely

matched to their needs. " We've had one size fits all ... now we'll have two

choices, " King said. Dr. Harlan Krumholz, a Yale University cardiologist

with no role in the study, noted that " in absolute numbers, for every 1,000

people you treat, you'd save a lot more heart events than you'd cause bleeds, "

because heart problems are more common. Cost also keeps many people from

taking Plavix now. Prasugrel's makers have not said what it would cost, but " if

they start competing on price, it could be a boon for the health care system, "

Krumholz said. ___On the Net: Heart Association:

http://www.americanheart.org New England Journal: http://www.nejm.org

 

http://news./s/ap/20071104/ap_on_he_me/heart_drug;_ylt=Ah4oHK5C7fvp3iSO\

S8mLX5Ja24cA

 

 

To treat cardiac arrest, doctors cool the body Updated 12/11/2006 12:44

AM ET

 

By Robert Davis, USA TODAY

 

When his heart stopped in the middle of his workday, Dean Cowles fell

clinically dead in one of the best places in the world to suffer sudden cardiac

arrest.

 

The 57-year-old engineer collapsed on July 18 in King County just outside

Seattle, a community that leads the USA in saving lives because of a commitment

to cutting-edge emergency medicine.

 

He was surrounded by co-workers who knew what to do when his body seized and

he gasped for air; for years they have taken classes in cardiopulmonary

resuscitation.

 

His heart quivered in an electrical short-circuit in a building in which Dean

and his friends make defibrillators, the device he would need — fast — if he

were to be revived.

 

A by-the-book rescue restarted Cowles' heart. But when he did not wake up

after his heart was restarted, his doctors say, he needed a treatment that most

Americans don't get — induced hypothermia — in which doctors lowered his body

temperature to about 91 degrees.

 

As Cowles' body struggled to recover from a cascade of biological problems

that can follow sudden clinical death, his heartbeat was strong but his brain

was competing with every other organ for oxygen.

 

Hypothermia therapy has for years been used in the operating room when doctors

want to slowly reduce a patient's need for oxygenated blood during heart and

other surgeries. While researchers do not fully understand why, studies have

shown that cooling allows the body to get by with less oxygen by decreasing the

metabolic demand.

 

When King County paramedics rolled Cowles into the emergency department at

Evergreen Hospital Medical Center two miles from his office, he had a strong

pulse but was still unconscious. The hospital team applied pads to his legs and

chest and used a machine to lower his body temperature.

 

" It's pretty much become the standard of care, " says Cowles' cardiologist,

Mark Vossler. " Cooling slows down the metabolism and decreases the brain's

demand for blood flow. That's the theory. "

 

Cooling the body gives the brain a break while other organs compete for oxygen

in a crisis, doctors say. Hypothermia protects the brain cells from damage, a

common problem following sudden death.

 

Cowles doesn't remember his hypothermic " coma, " which lasted about 24 hours.

 

The steps taken to save Cowles' brain illuminate a sharp medical disparity

across the nation. This hypothermia treatment is standard care in a few cities,

but it's unavailable in most.

 

Most doctors continue to give hypothermia the cold shoulder, despite studies

detailing the benefits in the New England Journal of Medicine in 2002,

international recommendations in 2005 urging the treatment, and inclusion in the

most recent American Heart Association's lifesaving guidelines for cardiac

arrest care.

 

Most physicians (87%) surveyed in a study published this year in the journal

Critical Care Medicine said they had not used hypothermia after cardiac arrest.

But doctors who have seen their own patient survival rates soar say people in

the same condition that Cowles faced should not be denied cooling therapy.

 

" Delaying acceptance of a therapy that has little risk but potentially great

benefit and really little cost is not patient-oriented, " says Clifton Callaway

of the Safar Center for Resuscitation Research at the University of Pittsburgh.

He says doctors must include cooling so that if a patient who arrives at the

hospital with a heartbeat after suffering a cardiac arrest goes on to die, " it's

not because of something we neglected to do for the patient. "

 

" Sometimes nature just holds all the cards, " says Callaway. " But you don't

want for it to be that you left cards on the table. "

 

How cooling helps

 

As Cowles' co-workers at Medtronic's Emergency Response Systems office

performed CPR, they each saw for the first time what a freshly dead person looks

like. After his body tensed up like he was having a seizure and he made gasping

and groaning noises, all of his muscles went flaccid. He was lifeless. " He

started to go gray, " says Cowles' boss, Steve Firman.

 

After CPR and two shocks from the automated external defibrillator (AED) kept

on the kitchen wall at the office, " Dean's pulse came back, " Firman says. " He

started breathing on his own. It was like a field of pink washed over his face. "

 

But, Firman adds, all his co-workers could then do was " hover " and wait for

paramedics to arrive about eight minutes later. " Dean did not regain

consciousness on the spot, " he says. They knew their friend was still in serious

trouble.

 

Many of the cardiac arrest victims who are revived across the USA with CPR and

rapid defibrillation make it to the hospital with a pulse, but they do not walk

out. Brain damage can be severe.

 

Cowles collapsed in a city that leads the nation in its attempts to save more

lives — by training more residents in CPR, deploying more AEDs and measuring the

performance of its paramedics.

 

Nearly half of the people like Cowles survive and walk out of Seattle-area

hospitals. On average across the nation, experts say, fewer than 10% are that

lucky.

 

But increasingly, other cities — among them Rochester, Minn., and Austin — are

following Seattle's lead and using hypothermia and other strategies to increase

survival rates for sudden cardiac arrest.

 

While last year's survey indicated some doctors are waiting for more research,

and one study underway is trying to determine the best time to start and stop

the cooling therapy, the gold standard of studies may no longer be possible

because of ethical concerns.

 

The best test of a clinical treatment is often to randomly put patients with

the same medical condition into two groups, one that gets the therapy and one

that does not, and then measure the results to determine if those who got the

treatment fared better.

 

But some doctors say hypothermia treatment is so clearly beneficial that it is

now unethical to deny one group a procedure known to be effective.

 

" I could no longer participate in a study that randomized somebody to not get

cooled, " says Mary Ann Peberdy, an associate professor of medicine at Virginia

Commonwealth University in Richmond. In her hospital, VCU Medical Center,

staffers began cooling their cardiac arrest survivors more than two years ago

and doubled survival rates. " I've made my survival twice as good. I couldn't go

back. "

 

Nurses from the intensive care unit tell Peberdy " we've never seen people wake

up and walk out of here like we are seeing now, " she says. " We're really doing

something good. It gives you chills. "

 

Raleigh, N.C., is not waiting.

 

The doctors who oversee Wake County EMS, which serves about 775,000 residents

across 860 square miles surrounding the city, reviewed the scientific literature

and in October began cooling their cardiac-arrest survivors.

 

" We believed it was not ethical to withhold the treatment in a randomized

way, " says Brent Myers, EMS medical director. " All patients who meet criteria

are considered for treatment. "

 

In Wake County, and across the nation, each segment of the emergency medical

system tends to operate in its own narrowly focused trench. Paramedics are the

first to treat cardiac arrest patients with advanced life support. The patient

is then handed off to emergency room physicians. If they're still alive after an

hour or more, the patient is then moved to an intensive care unit, where that

team takes over.

 

" Hypothermia is a therapy that, for the patient to benefit from it, the whole

system has to be integrated, " says Callaway, an associate professor in emergency

medicine at the University of Pittsburgh.

 

In Wake County, it was the ambulance service that led the way. " Typically, the

EMS field waits years for hospital-based or lab-based treatment protocols to

trickle down to pre-hospital care, " says Jeffrey Hammerstein, Wake County EMS

spokesman. " Our docs did the research and pushed this program up through the

hospitals. With a lot of cooperation and work, they came on board. "

 

Myers says " willing champions … both doctors and nurses " in the hospitals'

emergency departments and intensive care units gave the program a lift. " Without

their support, we would not have been able to have the unified approach we have

today. "

 

Now, Wake paramedics begin the hypothermia treatment in the field by

administering a sedative that prevents shivering, applying ice packs and

infusing chilled intravenous fluids. The paramedics then bypass three hospitals

with cardiac arrest survivors to take those patients to two hospitals, WakeMed

Raleigh and Rex health care, that provide cooling therapy.

Callaway says that by bypassing the closest hospitals to go to more

specialized heart centers, Wake County EMS may be taking the next big step in

cardiac-arrest care. Just as some trauma centers specialize in critical care,

some hospitals might concentrate on treating cardiac arrest survivors.

" In some ways, cardiac arrest patients are sicker than trauma patients, " he

says. " Right now we take them to the closest hospital, and that facility might

see one or two of those patients a month. It's not an equitable matching of

resources and patient need. "

 

A happy ending

 

In Redmond, Wash., Dean Cowles is back at work as a troubleshooting engineer,

as sharp as ever, his friends say. His emotions are closer to the surface. He's

more likely to laugh or shed a tear.

 

Cowles says he is enjoying the holiday season more with his wife, Diana, and

his sons, Dan and Ray. But he can't enjoy his vices anymore. When he collapsed,

he says, " I had what you call butter veins. " Now, on his heart-healthy diet, the

rule appears to him to be: " If it tastes good, spit it out. "

 

He jokes that the hypothermia treatment helped him quit his smoking habit. He

says he got to sleep through the first day of nicotine withdrawal.

" I went down a smoker and woke up a non-smoker, " he says. On a serious note,

he says that " hypothermia probably prevented brain damage. " He looks at his

co-workers, who begin to laugh. " Well, " he says, " the jury is still out on my

brain damage. "

 

Posted 12/11/2006 12:18 AM ET Updated 12/11/2006 12:44 AM ET

 

http://www.usatoday.com/news/health/2006-12-10-body-cooling-cover_x.htm?csp=N009

 

TRAINING, ACTION SAVED A LIFE The first thing that caught

Oscar Rojas' attention was a grunting sound, he recalls, like somebody trying to

lift a heavy box.

 

Rojas rounded the corner to find his friend, Dean Cowles, in serious trouble.

Over the next five minutes, Rojas and his colleagues would save a life in a

step-by-step manner pulled right from the American Heart Association guidelines.

The help they gave to Cowles, doctors say, is a reminder that simple steps can

turn a workplace into a safer place.

 

" If this had happened to Dean at home, he most likely would not be here now, "

says his cardiologist, Mark Vossler.

 

Cowles' employer had offered training in cardiopulmonary resuscitation. And

the company had equipped its offices with an automated external defibrillator or

AED, the device so simple that children can use it to save a life.

 

Having an AED on hand is a no-brainer for this particular office Medtronic's

Emergency Response Systems, which manufactures external defibrillators.

But it's the people, studies have found, who save lives. In fact, in places

where the devices have been locked away in cabinets or where employees were

untrained, people have died near AEDs that were never turned on.

 

Cowles was one of the lucky ones because his friends were ready. As Rojas

checked Cowles, Steve Copeland and another colleague grabbed the AED, and they

rushed to Dean's desk. Copeland and Rojas performed CPR and shocked Cowles 31

seconds after turning on the AED.

 

As they gathered recently to recall that day, the co-workers described the

surreal feeling when the machine they made told them to shock a friend. " I

thought, 'This is not a test. This is not a patient simulator,' " Rojas says. "

'My God, this is Dean!' "

 

Two shocks and good CPR restarted Cowles' heart. His face, which had turned a

shade of ash, began to flush again with pink.

 

" It's amazing, " Copeland says, " to see all of the training, all of the

technology built into the units; everything doing what it's supposed to do. "

 

HOW THE PROCESS WORKS 1. After a heartbeat is

restored, paramedics put cold packs in the armpits and groin and infuse chilled

intravenous fluids.

2. Doctors and nurses can use ice or cold packs, a catheter to cool the

bloodstream, or apply external pads to keep the body at 91.4 degrees.

 

3. Doctors keep the patient cooled and sedated for 12 to 24 hours before

rewarming the patient.

 

 

 

--------------------------

 

 

 

 

 

 

 

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