Almost anywhere else, the ambulance crew would have gathered up Buddy LaRosa in mid-heart attack and roared off to the closest emergency room.
They arrived that hot summer afternoon to find a classic cardiac emergency, the kind suffered by more than 1 million Americans a year. LaRosa had just climbed out of his pool from swimming laps, and he had an awful pain in his chest. His left arm was numb.
Soon the paramedics had a dozen electrocardiograph leads hooked to his chest. The spiky waves showed an ominous pattern. ST-segment elevation, they call it, the worst kind of heart attack.
Somewhere inside his heart, a blood clot had blocked one of the major arteries. Muscle downstream from it would starve and die unless something was done, and fast.
So the usual practice of heading for the nearest medical facility — in this case, a perfectly competent community hospital just five minutes from LaRosa’s house — would seem to make perfect sense. There, he would probably get a shot of a clot-dissolving drug, standard treatment since the mid-’80s.
But heart attack treatment has undergone a quiet revolution, one that ambulance services and small hospitals have largely ignored. Many heart specialists now agree that the clot-dissolving drugs are passe, or should be, and large hospitals have generally stopped using them. Instead, the best treatment is an emergency procedure called a primary angioplasty.
Big demand, small supply
Even more reliably than clot drugs, it can stop a heart attack cold if done within the first two or three hours. But it is available only at major hospitals with top-tier cardiac centers.
So the little community hospital is no longer the ideal place to treat a heart attack, especially if it occurs within driving distance of an angioplasty center, as the vast majority do.
Nevertheless, specialists estimate that only about a third of heart attacks in the United States are treated with primary angioplasty. Most end up at hospitals that can’t do them, and they aren’t transferred to places that can.
So the most remarkable thing about LaRosa’s otherwise run-of-the-mill heart attack last July was what happened after the medics loaded him into their big red ambulance. They raced right by that community hospital, then past another one, eating up 20 precious minutes to deliver LaRosa to Cleveland Clinic Florida, a new hospital in Fort Lauderdale’s lush western suburbs. The medics transmitted LaRosa’s EKG ahead, giving the four-member angioplasty team time to get ready.
Twenty minutes after they wheeled him through the ER doors, LaRosa was stretched out in the second-floor catheterization lab beneath a big overhead X-ray camera. The pictures showed his right coronary artery blocked. Quickly, Dr. Howard Bush pushed a wire through the clot, then briefly inflated a balloon.
The obstruction disappeared. The heart attack was over.
Primary angioplasty proves superior
LaRosa’s experience was unusual because the Broward County ambulance service is one of the nation’s few with a policy of driving heart attack patients to medical centers that can do primary angioplasty.
“In our community, this system has worked,” says Bush. “I know we are saving lives.”
Elsewhere, though, patients typically get such treatment only if they end up at an angioplasty hospital by chance.
“It’s really wrong what’s going on,” says Dr. Barry Kaplan, cath lab director at New York’s Long Island Jewish Medical Center.
Evidence has been building since the late ’80s that angioplasty works better than clot drugs, and cardiologists seem to have agreed with that conclusion in the past five years.
“Every study that comes out shows that primary angioplasty is superior, almost without exception,” says Dr. Gregg Stone, director of cardiovascular research at Lenox Hill Hospital in Manhattan.
Many specialists were skeptical when those studies began, remembers Dr. Cindy Grines of William Beaumont Hospital in suburban Detroit, who led some of the pioneering research.
But now there have been 23 such comparisons. Taken together, they suggest that about 9 percent of heart attack victims die after getting clot drugs, compared with 7 percent following primary angioplasty. The risk of recurring heart attacks drops in half, from 7 percent to 3 percent, and strokes — the most serious complication of the clot drugs — fall from 2 percent to 1 percent.
The goal of both treatments is to restore blood flow in the heart. Primary angioplasty does this in 95 percent of cases, while the clot drugs succeed in about two-thirds.
The business of hospitals
So if angioplasty’s benefit is unquestioned, why do most victims still get a less effective treatment?
Doctors estimate that fewer than one in five hospitals can offer emergency angioplasty around the clock, and some people live too far away. However, about 80 percent of the population lives within an hour’s drive of an angioplasty center.
Grines believes the real reason has more to do with economics. “There is no incentive to change,” she says. “The small hospitals don’t want to divert patients to larger hospitals, because that is lost revenue.”
Heart attack treatment, in fact, is one of the most profitable hospital services. While more could add primary angioplasty to their repertoires, most will not, because building and staffing the labs is too expensive. Even then, results can be poor unless the angioplasty teams handle plenty of cases to keep their skills sharp.
Even if smaller hospitals were willing to send their heart attack patients elsewhere for angioplasty, many worry that the time lag will be harmful. Maybe a quick injection of clot dissolver is better than waiting an hour or two.
The issue is still being debated. A recent study from Denmark found that even with the delay, patients taken to small hospitals have better outcomes if they are shipped off for angioplasty. But another new analysis from the University of Michigan concludes that the procedure’s advantages disappear if treatment is delayed more than an hour and a half.
Finding the right fix
One solution would be for ambulances to head straight for angioplasty centers, as Broward Fire Rescue does. However, in most places, the ambulances are operated by a pastiche of private, city, county and hospital ambulances with little incentive to drive farther than necessary. Any whiff of change would probably bring protests from smaller hospitals.
“There are a lot of strong community hospitals that aren’t offering primary angioplasty and would line up all their politicians against an effort to have heart attacks taken away from their hospitals,” says Dr. Joseph Carrozza, chief of interventional cardiology at Boston’s Beth Israel Deaconess Medical Center.
Nancy Foster, a senior policy analyst at the American Hospital Association, questioned whether it is even safe for ambulances to abandon the long-standing policy of taking heart attack patients to the closest hospital.
“If Broward wants to experiment, more power to them,” she said. “Until we have some evidence it is more effective and learn the limitations about how far you can transport patients safely, we would be hard-pressed to suggest it should be adopted nationally.”