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Speedy care for Florida's hearts

By A TIMES EDITORIAL
Published March 21, 2007

Rapid diagnosis and treatment of heart attacks represent a continuing challenge despite advances in diagnosis and therapy. In a heart attack, one or more blood vessels that supply the heart muscle with oxygen become blocked by clots. The most serious of these heart attacks are called "STEMIs" (which stands for ST-segment elevated myocardial infarction.)

State-of-the-art medical treatment for STEMIs focuses on removing the clot as quickly as possible to restore blood flow and oxygen to the heart muscle. If there is a long delay in treatment, it may be too late to save the heart muscle, and the patient may die or suffer long-term disability.

Two strategies have proved effective in removing clots: injection of clot-dissolving drugs or mechanically opening the artery by balloon angioplasty.

Recent evidence supports the superiority of angioplasty over drug treatment alone, if angioplasty is performed within 90 minutes of first patient contact. This approach was given formal approval by the American Heart Association last year.

In order to meet this time in the majority of STEMI sufferers, a number of time-saving strategies must be in place. Initially, these strategies focused on the hospital. The initial goal was to reduce the time from when the patient appeared at the hospital door to the time blood flow was re-established; this goal is called the "door-to-balloon" time or "D2B" for short. While hospitals recognize the importance of achieving a D2B time of less than 90 minutes, this goal has been difficult to meet for all patients, especially during off-hours and on weekends.

Recently, it has been recognized that significant time savings can be achieved by beginning the evaluation process in the ambulance. Making the diagnosis at the scene (home or field), rapidly initiating therapy, transferring the STEMI patient directly to a hospital capable of performing angioplasty in a timely manner, and activating the angioplasty team while en route can save from 30 minutes to 3 hours.

The recent successes of regionalized STEMI care in cities such as Boston, Minneapolis and Ottawa, Canada, argues strongly for regionalization. These programs have demonstrated that the 90-minute limit from first responder contact to re-establishing blood flow is achievable in a majority of STEMI patients.

The good news for our communities is that a regionalized STEMI triage and care program has begun in Hillsborough County. This program has taken more than five years of effort with the participation of all Hillsborough County hospitals and EMS services.

The time is appropriate to regionalize STEMI care for the entire state of Florida. There are a number of ways this can be accomplished. One is to define regions anchored by successful regional and hospital network STEMI programs. While many of these are located in major population centers, they are fairly well distributed throughout the state. The centers would be supplemented by air ambulance service to provide transportation from outlying locations or in high-density areas such as Miami, where transportation of a few blocks can result in an unacceptable treatment delay.

There are hurdles that must be overcome to operate a truly effective system. The first is the need for a commitment by the governmental organizations to support and foster this program. Second, all stakeholders and professional and trade organizations affected by the program must agree on specific language, transport and treatment protocols, and a robust quality assessment program. That will require the sharing of information with a central registry. Third, the protocols must consider local conditions that can influence transportation of STEMI patients and timeliness of therapy.

Florida is extraordinarily positioned to be a national leader in the treatment of STEMI patients. The Heart Services Improvement Act will come before the Legislature this session. This bill, if enacted, will provide the formal structure for statewide, regionalized STEMI care as have similar Florida laws governing stroke and trauma care. It needs our support.

Joel A. Strom, M.D., co-chair, Hillsborough County STEMI Committee

Charles Sand, M.D., chair, Florida American Heart Association STEMI Task Force

Elizabeth M. Barnett, Ph.D., associate professor, College of Public Health, University of South Florida

David Travis, Rescue Division chief, Hillsborough County Fire Rescue

Nicholas LoCicero, Rescue Division chief, Tampa Fire Rescue

[Last modified March 20, 2007, 21:19:50]