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Some Hospital Transfers in Heart Cases Potentially Harmful

Long delays to surgery may warrant new treatment strategies, experts say

MONDAY, Feb. 7, 2005 (HealthDay News) -- Transferring a heart attack patient to a hospital equipped for advanced artery-opening surgery such as angioplasty, rather than the quick use of clot-dissolving drugs, can cause potentially harmful delays in treatment, a new study finds.

That's because long transport times mean patients may not receive angioplasty within the time limit recommended by treatment guidelines, explained Dr. Harlan Krumholz, a professor of medicine at Yale University School of Medicine, and lead author of a report focusing on more than 4,000 of these patient transfers.

In a second study, experts say they've devised a guide to help surgeons decide whether patients with heart attack are better off undergoing bypass or less invasive angioplasty.

Both studies appear in the Feb. 7 online issue of Circulation.

Angioplasty, in which surgeons use a tiny balloon to open a blocked artery, should begin no more than 90 minutes after hospital admission for heart attack, according to guidelines set by the American Heart Association (AHA), the American College of Cardiology and the European College of Cardiology.

The same guidelines also mandate that clot-busting drug treatments be started within 30 minutes, especially because they are usually less effective in re-opening arteries than surgical interventions such as angioplasty.

However, in their study of nearly 4,300 patients transferred to 419 hospitals, Krumholz' team found that just 4.2 percent of patients received needed angioplasty within 90 minutes of first admission for suspected heart attack. In 55 percent of patients, delays lasted for between two to four hours, while for nearly 29 percent more, delays lasted four hours or more.

"That's a long time if you're having a heart attack," Krumholz said. "Coming to a hospital with a heart attack means that every minute counts. We need to think of ways to do it faster."

If transfers are made, hospitals on both the sending and receiving end need to minimize the time required for angioplasty to begin, he said.

"If you are a transfer hospital, you should be working in parallel with the sending hospital," he said. "If the patient is on the way, you should be getting everything ready. Sometimes the hospitals work in sequence, re-evaluating the patient all over again in the transfer hospital."

Transfers need to be carefully considered because a number of studies suggest the best strategy is to get heart attack patients to the nearest hospital emergency room -- whether or not it is equipped for angioplasty, Krumholz said. While only about 25 percent of U.S. acute-care hospitals are equipped to perform angioplasty, clot-busting drug treatment is now available in any emergency room, he said.

"There is a slight advantage to angioplasty, because it is less invasive and is less likely to cause bleeding," he said. "But if you can't do it quickly, you can use a clot-busting drug."

The new study should spur hospitals to re-examine the time needed to transfer patients and make decisions accordingly, Krumholz said.

"If the two hospitals are side by side, transfer makes a lot of sense," he said. "But if there are possible delays because of distance or traffic, the effects of delay should be included in a decision. Hospitals tend to look only at their own data, to see whether a patient is treated within two hours or so after admission. Nobody is counting the total time to treatment."

Another report in the same issue of the journal concerns a longer-term decision regarding heart attack treatment: Whether a patient will be better off getting bypass surgery, to reduce the need for repeat angioplasties due to artery re-closing.

"That is often a difficult decision," said Dr. John Spertus, director of cardiovascular education and outcomes research at the St. Luke's Mid-America Heart Institute in Kansas City, Mo. "At this point, it's often based on the [hospital's] technical ability to do both procedures."

Spertus and his colleagues have devised a new rating scale to guide doctors making this difficult decision. Each patient is assigned a point score based on his or her medical conditions. For example, four points are given for diabetes, having daily chest pain is worth three points, having a past angioplasty is worth two points.

In 546 patients with a point score of four or less, the researchers found no benefit to bypass over angioplasty. Bypass surgery had the greatest advantage in terms of reduced incidence of recurrent chest pain, angina, in the 235 patients with a score of eight or more.

"We envision this scale as a real help to a physician in making the decision," Spertus said. "We are re-examining this model and are starting to build additional predictive models of patient outcome. We are also trying to understand what additional information could be bundled into the scale, so that doctors could be able to select the right therapy for the right patient."

More information

A guide to heart attack treatment is available at the American Heart Association.

SOURCES: Harlan Krumholz, M.D, professor, medicine, Yale University School of Medicine, New Haven, Conn.; John Spertus, M.D., director, cardiovascular education and outcomes research, St. Luke's Mid-America Heart Institute, Kansas City, Mo.; Feb. 7, 2005, Circulation online
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