Image: x-rays
Toby Talbot  /  AP
Dr. Harold Dauerman checks monitors during a catheterization lab heart procedure in Burlington, Vt. on Sept. 23. A cutting-edge method gets heart attack victims treated fast, by delegating decisions to colleagues in remote hospitals and, in some cases, with specially-equipped ambulances.
updated 11/16/2008 11:49:43 AM ET 2008-11-16T16:49:43

The last thing Erik FitzPatrick remembers of the Corporate Challenge road race, he was waving to his wife and young daughter as he neared the finish line.

That’s when he went down with a massive heart attack. Fortunately, runners behind him in the May 15 race in Montpelier started CPR, and an ambulance arrived within minutes.

“Evidently, I was dead,” FitzPatrick said.

The next day, he woke up in the hospital. He doesn’t remember being resuscitated twice in the street. He doesn’t recall being taken to Central Vermont Hospital and then transferred the 40 miles to Fletcher Allen Health Care in Burlington, where physicians opened his clogged artery about 90 minutes after he hit the pavement.

FitzPatrick, who’s 43, figures he was lucky to have the heart attack where he did, and not while running alone. But the system that got him to Burlington so fast was anything but luck.

Physicians at Fletcher Allen have been working with their colleagues to provide heart attack patients lifesaving treatment in minutes rather than hours, even if they fall ill in remote parts of the state. The program uses technology and teamwork, and takes advantage of a change in state rules.

But the effort to get such high-risk patients to the appropriate hospital within 90 minutes is nationwide. Only about a quarter of all hospitals are capable of doing the procedure.

Over the last two years, a system was honed to ensure that all patients who arrive at the Burlington hospital can get needed treatment in 90 minutes, the national goal set by the American College of Cardiology and the American Heart Association. Now, that system has been expanded to include regional hospitals in St. Albans, Morrisville and Berlin, where the goal is to ensure the same speedy treatment as delivered in Burlington.

“This is really one of those landmark breakthroughs in emergency cardiac care,” said Dan Manz, chief of emergency medical services for the Vermont Department of Health, who helped develop the procedures.

Delays increases chance of death
The types of heart attack that need such aggressive treatment are those in which the arteries are completely blocked, a condition called ST-elevation myocardial infarction, or STEMI. In the more common non-STEMI heart attacks, arteries are only partially blocked, so some blood is still reaching the heart muscles.

“STEMIs are a fire drill. Every 30-minute interval that goes by, mortality increases significantly,” said Dr. Harold Dauerman, director of Fletcher Allen’s Cardiac Catheterization Laboratories. “On the other hand, non-STEMI’s are not as time-pressured. If you catch them within four to 48 hours of the presentation, they do very well.”

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In STEMI patients, a catheter is inserted into a leg artery, fed into the blocked artery around the heart and then a balloon is expanded to open the artery. A wire mesh tube called a stent — about the size of a ball point pen spring — is placed at the spot of the blockage, to keep it open.

The emphasis on opening arteries with the balloon and stent was developed in the early years of this decade after it became clear the procedure is significantly better than using clot busting drugs — if the procedure can be performed quickly enough.

The American Heart Association estimates almost 400,000 people a year suffer STEMI heart attacks.

Last year, the organization launched its program “Mission: Lifeline,” whose goals are similar to those being put into practice in northwestern Vermont. But only 8.6 percent of STEMI patients nationally who need to be moved between hospitals receive the procedure within the 90-minute window, said Dr. Alice Jacobs, a cardiologist at Boston University and past president of the American Heart Association who’s helping lead the Mission Lifeline campaign.

“Those patients who do not have their artery opened within 90 minutes have a higher chance of dying from the heart attack,” Jacobs said. For every 30-minute delay from the onset of symptoms to opening of the artery, she said, the mortality rate increases by 7.5 percent a year later.

“It really takes a system of care, particularly in rural areas,” said Jacobs.

One of the first large areas to develop such a system was in Minnesota. Now 35 hospitals and 11 clinics throughout the state have a system in place to get STEMI patients to Minneapolis for treatment, although some patients are treated at other hospitals as well, said Dr. Tim Henry of the Minnesota Heart Institute.

“When I started talking about this there was a lot of push-back,” Henry said. “In 2003ish the majority were naysayers.”

But the system cut in half the number of heart attack deaths, and also cut the length of hospital stays and reduced other complications, he said.

Now there are 50 to 60 such systems across the country.

The first step to set up such a system at Fletcher Allen was to require that an on-call team that does the angioplasty always be available within 30 minutes. Now, 100 percent of STEMI patients who arrive at Fletcher Allen are treated within 90 minutes of coming through the door. Once Fletcher Allen could do it, the goal was set for the outlying hospitals.

“We work by e-mail directly with all the (emergency department) directors and the ED staffs throughout the region to make sure we have a very slick system, sort of a bat-phone approach, one phone call gets the whole ... team here, gets everything going,” said Dauerman.

Increasingly, ambulances are equipped with special heart monitors that can determine if a STEMI heart attack is taking place. EMTs are being trained to read the data. In some cases, the information can be transmitted directly to a hospital where a physician can read it.

So, for example, if a man in Stowe has a STEMI heart attack, an ambulance can take him straight to Fletcher Allen, rather than going first to a hospital in Morrisville, which is closer, as standard ambulance procedure requires.

Making that change wasn’t as simple as it sounds. Vermont rules once required that ambulances take patients to the nearest hospital.

Today, the STEMI patient who arrives in St. Albans, for instance, isn’t even taken off the ambulance stretcher.

“In a lot of cases we can get the patient out and on the road in less than 15 minutes,” said Dr. Marc Kutler, an emergency room physician at Northwestern Vermont Medical Center. “The more you do it, it gets more organized, it gets fine tuned.”

For patients too far away to reach Fletcher Allen in time to meet the 90-minute goal, physicians will treat them using a combination of clot-busting drugs followed by the balloon when they reach the hospital.

Running again
In retrospect, FitzPatrick, who lives in South Burlington, said he’d noticed the tightness in his chest during several training runs before he started the Corporate Challenge. He ate right and exercised and — being so young — didn’t consider himself a heart attack candidate.

Then he died on the street.

Six months later, he has recovered 100 percent. Blood flow to his heart was restored so quickly there was no permanent damage.

“Here he is in this race when he had his cardiac arrest,” said Dr. Matthew Watkins, who treated him at Fletcher Allen. “Then another race started with incredibly high stakes. He went from this race to another medical race for which he got the gold medal.”

Better yet, he got his life back and he’s running again.

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