hgazette.com, Haverhill, MA

November 29, 2012

Heart attack treatment: A cardiologist's retrospective

By Kenneth Adams, MD
FACC

---- — Editor’s note: The Gazette publishes occasional columns from local medical experts. This is one of those columns.

I was 10 years old when Mike G. died, and it was the first time I was old enough to understand the impact of a death.

My family lived on a small suburban street and we all knew each other. Mike, the head of a large family, was strong, energetic and only 49 years old. He had a heart attack while mowing his lawn. At that time, they called it a coronary thrombosis, but I didn’t know that meant a blood clot in the heart until years later.

When I was 31 and starting my medical internship at a large hospital in the midwest, my first rotation was in the Cardiac Care Unit (CCU). One night, I was taking care of a patient who came in with chest pain due to a clear-cut heart attack. At the time we called it a transmural myocardial infarction, which meant it affected the full thickness of the heart muscle. The nursing staff and I felt helpless because there was very little in the CCU “medical toolbox” to help him.

Then in 1988, a very important study was published in the New England Journal of Medicine showing that most of the time when a heart attack occurs, there is a blood clot in one of the vital arteries feeding the heart muscle. This is what my neighbor Mike G. died from. The clot occurs when a plaque lining the wall of an artery ruptures. The body’s natural response is to try to repair the plaque rupture by triggering clot formation.

This landmark study led to revolutionary changes in treatment of those types of heart attacks, which are no longer called transmural myocardial infarctions. Today, they are called ST segment elevation MI or STEMI — a term that reflects what we see on the EKG when a blood clot and plaque block one of the coronaries feeding the heart muscle.

A significant advance in treatment was to give clot buster medications to dissolve the clot in the affected artery, in order to restore blood flow to that part of the heart. Our mantra was, and still is, “time is muscle,’’ meaning the sooner we get the artery open to restore blood flow to the heart muscle, the more heart muscle function we can save.

But we didn’t always know if the medication was effective. And even if treatment seemed successful, we still had the dilemma of deciding whether the patient should undergo a cardiac catheterization to assess the coronary arteries and evaluate if balloon angioplasty should be done.

Why not just get in there, see if the artery is clogged and fix it? Some pioneers in heart attack treatment were doing just that, and today that process, called acute intervention, is considered state-of-the art treatment for STEMI.

When a patient presents within a four to six hour window with signs and symptoms of a STEMI, our goal is to get that patient to the nearest Cardiac Catheterization Lab as soon as possible. Cardiac catheterization will determine the culprit artery so a stent can be inserted to open the artery and restore blood flow to the heart muscle.

We judge our success in several ways: Preserving the patient’s life, preserving heart muscle function, and preventing further heart attacks, to name a few. We also measure something called “door to balloon time.’’ This means how quickly we go from diagnosis of the heart attack (starting when the patient comes through the door) to when we treat the culprit artery (with a balloon/stent). We want this time to be 90 minutes or less because time is muscle.

I don’t know if my neighbor Mike G. would have survived if we were able to offer one of these advanced treatments, but he definitely would have had a better chance.

The CCU patient I tried to help in 1979 was just a stretcher trip away from the Cardiac Catheterization Lab in the hospital, but balloon angioplasty was not part of cardiac practice at that time.

Our future goals include lots of attention toward prevention. How do we get people to follow a lifestyle that will reduce cardiac risk? What are the best medicines to reduce heart attack risk? How do we identify who has a vulnerable plaque that might rupture and cause a heart attack?

Judging by how rapidly heart attack treatment has changed in just a short time, maybe those answers are not too far away.

Kenneth Adams is senior cardiologist and director of intensive care and telemetry at Merrimack Valley Hospital.