Weekend Heart Attacks Can Be Deadlier

Patients less likely to get artery-opening procedures, study says

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WEDNESDAY, March 14, 2007 (HealthDay News) -- Heart attacks treated on a Saturday or Sunday are more deadly than those attended to during the week, a new study shows.

That's because patients rushed to the hospital on weekends are less likely to receive timely angioplasty and other artery-opening procedures, researchers say.

"If you go to many hospitals, it is understood that the availability of personnel, the availability of equipment, and the associated administrative mechanisms are not the same on the weekends," said study author William Kostis, a researcher in the department of medicine at the University of Medicine and Dentistry of New Jersey, in New Brunswick.

His team reported the findings in the March 15 issue of the New England Journal of Medicine.

But other experts noted that the data in the study is at least five years old, and that a recent nationwide push by the American College of Cardiology (ACC) and the American Heart Association (AHA) to improve heart-attack care may have already eased the problem.

"I'd be hopeful that the data, if measured today, would reflect that level of intensity and scrutiny that we have been giving it over these years," said Dr. David A. Meyerson, director of cardiology consultative services at Johns Hopkins Bayview Medical Center in Baltimore, and a national spokesman for the AHA.

A cardiologist on the front lines of emergency care took a similar view.

"I'd be willing to bet now that if you looked at our numbers, you could get into the (cardiac) catheterization lab faster at nin o'clock on a Saturday night than you can at one o'clock on a Tuesday afternoon," said Dr. Frank Smart, chairman of cardiovascular medicine at Atlantic Health, which oversees two of the New Jersey hospitals covered by the study.

The new findings aren't the first to suggest that the quality of emergency heart-attack care varies by time or date of admission to a hospital. For example, one 2003 study found that patients admitted to emergency departments in the early morning hours had lower survival rates compared to those who were admitted during the day or evening. Another 2004 study found that heart attacks were also more deadly during hospitals' understaffed holiday periods.

And just last week, Canadian researchers reporting in Stroke found that the short-term survival of stroke patients admitted to care on the weekend was 14 percent lower than those treated during the week.

The new study is one of the largest such reviews focused on heart-attack care to date.

"We have a very large unselected database," Kostis said. "We studied over 230,000 people who presented with their first heart attack over a 16-year period (1987-2002). Basically, we included all of the people who had their first heart attack and were admitted to a New Jersey hospital during that period."

Comparing 30-day death rates, the team found that mortality rose to 12.9 percent among patients treated on a weekend compared with 12.0 percent for those treated on Monday through Friday. Twenty-four hour death rates were also significantly higher for patients admitted on a weekend -- 3.3 percent of those patients died within a day of admission compared to 2.7 percent of patients who were treated during the week.

The approximately 1 percent absolute rise in patient mortality for weekend admissions persisted for more than a year, the researchers noted.

Factoring out patient demographics, coexisting illnesses and the anatomical site of a heart attack, the reason for the weekend disparity became clear: Patients who arrived on a Saturday or Sunday were less likely to receive potentially lifesaving procedures such as balloon angioplasty (with or without stents) and coronary artery bypass, the study authors said.

"If they came in on the weekend they were one-third less likely to get that [type of] procedure," Kostis said. He added that it was exactly these invasive interventions "that, in many studies, are associated with the best outcomes."

Smart readily admitted that emergency heart-attack care on weekends had been a problem at the two New Jersey centers he helps oversee, Morristown Memorial Hospital and Overlook Hospital. But he noted that the New Jersey data in the study ended in 2002. Not long after, he and cardiologists across the country -- prompted by initiatives from the ACC and the AHA -- redoubled their efforts to boost emergency department response times.

"Since that time, we have seen what we call 'door-to-balloon' times drop precipitously," Smart said. "Ninety minutes is what the ACC says is a reasonable time from when the patient hits the door of the ER to the time a balloon is in their artery, opening that artery up."

A few years ago, "door-to-balloon" time at Smart's hospitals was stuck at about 130 minutes, with each department involved in patient care pointing fingers at another when it came to blame.

"So, starting with every case that came in, we looked at every moment in the process," Smart said. "We analyzed each step: Were we on target? Over-target? Under-target? What went wrong? Why didn't it go well?"

That type of scrutiny has made each player in emergency heart-attack care at the two centers take full "ownership" of the problem, Smart said. The result: Average "door-to-balloon" time for patients has now been slashed to 70 minutes.

And other staffing and equipment innovations now mean that patients who arrive on a Sunday can expect the same high-quality performance as those treated on a Wednesday, Smart said.

"In fact, I can tell you that our shorter times, recently, have typically been on nights and weekends," he said.

The AHA's Meyerson said hospitals everywhere must remain vigilant to make sure heart attack care doesn't lag, however. "Care of a heart attack shouldn't be dependent on a weekend differential," he said. "Every hospital has an obligation to monitor this and be certain that the critical care that they provide is available 24/7 and that the quality is seamless."

All of the experts agreed that hospitals can only do so much to streamline systems and cut heart-attack mortality. A lot of it is up to the individual patient.

"Here's the big problem: Most people still sit at home for two, three, even four hours before they do anything and seek medical attention," Smart said.

Kostis agreed. "If you have symptoms that are suggesting that you are having a heart attack, get yourself to a hospital as quickly as possible," he said. "Recognizing the symptoms of a heart attack and getting yourself to a hospital is crucial."

More information

Find out how to recognize a heart attack at the American Heart Association.

SOURCES: William Kostis, Ph.D., researcher, department of medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick; Frank Smart, M.D., chairman, cardiovascular medicine, Atlantic Health, Morristown Memorial Hospital and Overlook Hospital, Overlook, N.J.; David A. Meyerson, M.D., director, cardiology consultative services, Johns Hopkins Bayview Medical Center, Baltimore, and national spokesman, American Heart Association; March 15, 2007, New England Journal of Medicine

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