April 8, 2007


Lessons of heart disease, learned and ignored (Gina Kolata, April 8, 2007, NY Times)

What few patients realize, Dr. Antman said, is that a serious heart attack is as much of an emergency as being shot.

"We deal with it as if it is a gunshot wound to the heart," Dr. Antman said.

Cardiologists call it the golden hour, that window of time when they have a chance to save most of the heart muscle when an artery is blocked.

But that urgency, cardiologists say, has been one of the most difficult messages to get across, in part because people often deny or fail to appreciate the symptoms of a heart attack. The popular image of a heart attack is all wrong.

It's the Hollywood heart attack, said Dr. Eric Peterson, a cardiologist and heart disease researcher at Duke University.

"That's the man clutching his chest, grimacing in pain and going down," Dr. Peterson said. "That's what people imagine a heart attack is like. What they don't imagine is that it's not so much pain as pressure, a feeling of heaviness, shortness of breath."

Most patients describe something like Mr. Orr's symptoms -- discomfort in the chest that may, or may not, radiate into the arms or neck, the back, the jaw, or the stomach. Many also have nausea or shortness of breath. Or they break out in a cold sweat, or have a feeling of anxiety or impending doom, or have blue lips or hands or feet, or feel a sudden exhaustion.

But symptoms often are less distinctive in elderly patients, especially women. Their only sign may be a sudden feeling of exhaustion just walking across a room. Some say they broke out in a sweat. Afterward, they may recall a feeling of pressure in their chest or pain radiating from their chest but at the time, they say, they paid little attention.

Patients with diabetes might have no obvious symptoms at all other than sudden, extreme fatigue. It's not clear why diabetics often have these so-called silent heart attacks -- one hypothesis attributes it to damage diabetes can cause to nerves that carry pain signals.

"I say to patients, 'Be alert to the possibility that you may be short of breath,' " Dr. Antman said. "Every day you walk down your driveway to go to your mailbox. If you discover one day that you can only walk halfway there, you are so fatigued that you can't walk another foot, I want to hear about that. You might be having a heart attack."

Other times, said Dr. George Sopko, a cardiologist at the National Heart, Lung and Blood Institute, symptoms like pressure in the chest come and go. That is because a blood clot blocking an artery is breaking up a bit, reforming, breaking and reforming. It was what happened to Mr. Orr when he was at the gym and meeting his friend afterward.

"It's a pre-heart attack," Dr. Sopko said. A blood vessel is on its way to being completely blocked. "You need to call 911."

But most people -- often hoping it is not a heart attack, wondering if their symptoms will fade, not wanting to be alarmist -- hesitate far too long before calling for help.

"The single biggest delay is from the onset of symptoms and calling 911," said Dr. Bernard Gersh, a cardiologist at the Mayo Clinic. "The average time is 111 minutes, and it hasn't changed in 10 years."

'Time Is Muscle'

At least half of all patients never call an ambulance. Instead, in the throes of a heart attack, they drive themselves to the emergency room or are driven there by a friend or family member. Or they take a taxi. Or they walk.

Patients often say they were embarrassed by the thought of an ambulance arriving at their door.

"Calling 911 seems like such a project," Mr. Orr said. "I reserve it for car accidents and exploding appliances. I feel like if I can walk and talk and breathe I should just get here."

It is an understandable response, but one that can be fatal, cardiologists say.

"If you come to the hospital unannounced or if you drive yourself there, you're burning time," Dr. Antman said. "And time is muscle," he added, meaning that heart muscle is dying as the minutes tick away.

There may be false alarms, Dr. Sopko said.

"But it is better to be checked out and find out it's not a problem than to have a problem and not have the therapy," he said.

Calling an ambulance promptly is only part of the issue, heart researchers say. There also is the question of how, or even whether, the patient gets either of two types of treatment to open the blocked arteries, known as reperfusion therapy.

One is to open arteries with a clot-dissolving drug like tPA, for tissue plasminogen activator.

"These have been breakthrough therapies," said Dr. Joseph P. Ornato, a cardiologist and emergency medicine specialist who is medical director for the City of Richmond, Va. "But the hooker is that even the best of the clot buster drugs typically only open up 60 to 70 percent of blocked arteries -- nowhere close to 100 percent."

The drugs also make patients vulnerable to bleeding, Dr. Ornato said.

One in 200 patients bleeds into the brain, having a stroke from the treatment meant to save the heart.

The other way is with angioplasty, the procedure Mr. Orr got. Cardiologists say it is the preferred method under ideal circumstances.

Stents have recently been questioned for those who are just having symptoms like shortness of breath. In those cases, drugs often work as well as stents. But during a heart attack or in the early hours afterward, stents are the best way to open arteries and prevent damage. That, though, requires a cardiac catheterization laboratory, practiced doctors and staff on call 24 hours a day. The result is that few get this treatment.

"We now are seeing really phenomenal results in experienced hands," Dr. Ornato said. "We can open 95 to 96 percent of arteries, and bleeding in the brain is virtually unheard of. It's a safer route if it is done by very experienced people and if it is done promptly. Those are big ifs."

Posted by Orrin Judd at April 8, 2007 11:11 AM
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