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 Researchers looked at how fast heart attack patients received what's
known as percutaneous coronary intervention (PCI), a preferred
treatment to unclog blocked arteries that isn't always available at
community hospitals. During a PCI procedure, surgeons insert a tiny
balloon and inflate it to open clogged arteries, then often place a
stent, a tiny wire mesh cage, to keep vessels propped open.
"If the patient can make it to a hospital with the ability to stent
the artery within 120 minutes, the patient will likely have a better
outcome and be less likely to die or have major residual problems
from the heart attack," said lead study author Dr. Jacqueline Green
of the Piedmont Heart Institute in Fayetteville, Georgia.
"Stopping at a community hospital first, when the nearest hospital
with stenting abilities is a short distance further down the road,
creates unnecessary treatment delays that can worsen patient
outcomes," Green said by email.
U.S. cardiologists recommend that heart attack patients should
ideally receive PCI within 90 minutes or less of their first contact
with a medical professional if they're taken directly to a hospital
with specialists who can perform the procedures, or within 120
minutes or less if patients first go to another facility and need to
be transferred.
For the study, researchers examined data on the timing of PCI for
19,287 heart attack patients treated at 379 sites across 12 states.
Six states had policies allowing ambulances to bypass local
hospitals to go directly to a specialized heart facility: Delaware,
Iowa, Maryland, North Carolina, Pennsylvania and Massachusetts.
Another six states did not: South Carolina, Minnesota, Virginia,
Texas, New York and Connecticut.
In states where ambulances could go directly to a site with PCI
capabilities, 57 percent of heart attack patients had these
procedures within 90 minutes or less, the study found.
Where ambulances had to go to the closest hospital, whether or not
it had PCI capabilities, only 45 percent of heart attack patients
received procedures within 90 minutes.
One limitation of the study is that researchers lacked data on where
patients had their heart attack or were picked up by ambulances,
making it impossible to calculate driving times to the nearest
community hospital or facility with PCI capabilities, the authors
note in Circulation: Cardiovascular Interventions.
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Part of the difference in time to PCI may have to do with whether
ambulances were set up to do an electrocardiogram (ECG) to properly
diagnose the patient and steer them to the right hospital, said Dr.
Kwan Seung Lee of Banner University Medical Center Tucson, Arizona,
who wasn't involved in the study.
Patients got ECGs in the ambulance in 75 percent of cases in states
that permitted bypassing local hospitals for a heart facility,
compared with 69 percent of cases in other states, the study found.
"This may actually have been the reason for improved performance,"
Lee said in an email.
Still, the results suggest that regional policies that direct
ambulances to PCI-capable hospitals for heart attack patients
expedite the care of these patients, said Dr. Daniel Kolansky of the
Perelman School of Medicine at the University of Pennsylvania in
Philadelphia.
"However, patients should not delay calling for emergency services
(911 in the United States) because the care delivered in ambulances
can be life-saving as well," Kolansky, co-author of an accompanying
editorial, said by email.
Patients who go to a community hospital might get treated with
clot-busting drugs, then transferred somewhere else for a PCI once
they're stabilized.
"When patients go to a hospital without immediate PCI-capability,
the emergency department physicians need to decide whether or not
they can transfer the patient to receive PCI within a certain
timeframe or, if transfer takes too long, to give . . .
(anti-clotting drugs) that the patient can receive through an IV,"
said Dr. Renee Hsia, a professor of emergency medicine and health
policy at the University of California, San Francisco.
"All things being equal, studies show that immediate PCI yields
better outcomes than IV (anti-clotting drugs), but if the transfer
time is too long, then IV (drugs) would be given in a hospital that
does not offer PCI," Hsia, who wasn't involved in the study, said by
email.
SOURCE: https://bit.ly/2GwiscS and https://bit.ly/2HSxuz8
Circulation: Cardiovascular Interventions, online May 1, 2018.
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