Alberta team boosts heart patients’ hopes
EDMONTON— Two years ago, Bob Harrison donned his choir gown in the basement of Edmonton’s Winterburn United Church and started to ascend the stairs for Easter service when he felt a sudden, strange pain in his shoulders, neck and the back of his arms.
A nurse in the choir told the 69-year-old piano teacher he was having a heart attack. When the ambulance arrived, Harrison received an injection of clot-busting drugs that would not only help open his coronary arteries, but also make him par tof an Edmontonled study that could change the way heart attack patients are treated around the world.
“The paramedics asked if I’d be willing to participate in the program and I said it’s fine, probably because I didn’t care at that point; I just wanted them to give me something,” said Harrison, feeling fantastic today at 71.
“But I think it’s important that if you have that happening, you need to participate,” Harrison said.
He was among 1,900 patients from 15 countries who were part of the study that was published Sunday in the prestigious New England Journal of Medicine. It investigated whether clot-busting drugs administered by paramedics in the first three hours after a heart attack, followed by an angioplasty, recovered as well as patients who received only the angioplasty in the initial three-hour window. The study found that they did.
With angioplasty, a catheter carrying a deflated balloon is fed into a patient’s coronary artery to widen it and target the blood clot that caused the heart attack. Plaque is squashed against the wall of the artery, allowing proper blood flow to the heart, and a tiny mesh embedded at the site of a blockage to permanently prop the artery open.
For several years, doctors have believed angioplasty is the better treatment. But the procedure needs to be per- formed in a specialty facility. There are only three Alberta institutions where patients can get one.
The longer it takes to open a blocked artery, the higher the danger of losing heart muscle and risking irreversible damage. A commute from a rural area, or even a traffic jam in the city, can cause dangerous delays for patients.
“We need to move the goalpost for patients out into the field and outside of hospitals,” said Dr. Paul Armstrong, the study’s co-lead researcher and a professor in the faculty of medicine and dentistry at the University of Alberta.
“We need to get to them earlier and we need to convince them to call sooner. There’s no one size for treatment that fits all, but you need to have strategic options. Both options are good, we need to choose the right option for the right patient at the right time.”
Organizing the four-year, international study was a tremendous feat for Armstrong and other researchers, who had to co-ordinate paramedics, doctors and medical facilities. Patients who called 911 soon after showing signs of a heart attack were asked to participate. The results of their electrocardiogram (ECG) were often sent by cellphone to a doctor in hospital for review.
The patient would then be randomly assigned either course of treatment. Paramedics had to be trained in administering the clot-busting drugs, a process that previously took several hours in hospital. Technological advances have meant the drugs can now be administered within a matter of seconds in an ambulance.
The study found it took 100 minutes, on average, for a heart attack patient to receive clot-busting drugs from the time that patient first started showing symptoms. It took an average of 178 minutes for patients to receive an angio- plasty. Patients who did not respond well to clot-busting drugs were immediately sent for an angioplasty, but twothirds of the patients who received the drugs went for an angioplasty later, sometimes as much as 24 hours later.
Armstrong said the pendulum has swung too far with doctors almost always favouring the immediate angioplasty treatment. He hopes the study will reveal advantages of keeping two treatment options.
“Use the pre-hospital system where the electrocardiogram and trained paramedics are able to deliver the right care in the community,” he urged. “It’s so much about time and monitoring your times. … If you’re going to wait longer than 90 minutes to 120 minutes to deliver (the angioplasty), then I think you’re doing your patients a disservice and that’s the wake-up call that I think (this study) will provide.”
Clot-busting drugs are expensive, but so is the cost of calling staff on short notice to open a catheter treatment room.
Armstrong said a cost analysis of the treatments must still be performed.