Time is muscle

Heart attack survival rates are on the rise, but cardiac specialists say they could be even higher if more people understood the importance of quickly recognizing the warning signs and immediately calling an ambulance.

BY JOEL SCHLESINGER
Winnipeg Health Region
Wave Magazine, Summer 2010

Mike Wolfson awoke one morning last April with a saucer-sized feeling of pressure in the middle of his rib cage.

Sitting up in bed and rubbing his chest, the 85-year-old man did a quick self-diagnosis: indigestion, he thought. An antacid should do the trick.

Then he looked at his bedside clock and noticed it was 3 a.m. It was, he thought, an odd time to have heartburn.

"Then I started to perspire," Wolfson says, recounting the events of that morning. "I knew that was it."

At that point, Wolfson realized he was having a heart attack. Now, he had only one thing on his mind - dialling 911 for an ambulance.

With that single phone call, the retired furniture salesman triggered a series of events that would eventually save his life.

Wolfson's story is not unusual. A heart attack is one of the most common - and certainly the most dramatic - manifestations of heart disease. It is estimated that about 1,500 people living within the Winnipeg Health Region suffer a heart attack each year. That works out to about 30 a week. And, like Wolfson, a growing number of these patients are surviving, in large measure because of changes in the way heart attack patients are diagnosed and treated through the Winnipeg Health Region's Cardiac Sciences Program.

Consider this: An ST segment myocardial infarction (more commonly known as a STEMI heart attack) is the most common type of major heart attack. In a STEMI, the coronary heart artery is completely blocked by a blood clot, and as a result, virtually all heart muscle being supplied by the artery starts to die. Five years ago, roughly 15 per cent of people who suffered a STEMI heart attack in the Winnipeg area died. Today, the mortality rate is only four per cent.

A large part of the reason for this improvement can be traced back to the Region's decision in 2004 to consolidate cardiac health under one program at St. Boniface Hospital. In doing so, the Region created a larger, more efficient program, one that has resulted in enhanced care and improved outcomes for patients.

Wolfson's story illustrates the point. His odds of surviving that morning were enhanced by two things: his ability to recognize the warning signs of a heart attack and his decision to immediately call an ambulance, thereby tapping into the STEMI Management Protocol - a relatively new rapid response system designed to let paramedics begin diagnosis and treatment of heart attack patients on the scene.

"In this case, we were very fortunate because Mike identified the symptoms relatively early," says Dr. James Tam, Chief of Cardiology with the Region's Cardiac Sciences Program. "If he had gone to any other hospital initially, he might not be here today. If it wasn't for this program (the STEMI Protocol), his life-saving treatment would not have been available when he needed it."

Of course, recognizing the warning signs can be tricky. Not all people experience heart attacks in the same way, and many don't know they are having one until it's too late.

The problem begins with the build-up of cholesterol-laden plaque in the coronary artery system. A heart attack occurs when an artery is blocked by a clot. This happens when a tear occurs in the artery's lining due to the build-up of fatty plaque in the vessel wall. Plaque spills out into the bloodstream, prompting the body to respond to the tear as it would if you cut your finger. Tiny platelets in the blood start patching up what the body has mistakenly identified as a wound. The result is that the artery becomes clotted with platelets, restricting the flow of oxygen-rich blood to the heart muscle. As blood flow stops, the muscle's cells start to die. And once the muscle is dead, that heart muscle function is lost because the heart can't grow new cells, unlike other parts of the body, such as the skin.

In many cases, a heart attack can be identified by a pressing, heavy pain or discomfort in the chest that is caused when the blockage occurs. But the warning signs can also be more subtle, and include symptoms such as a dull ache, squeezing discomfort or tightness in the chest area, pain shooting up into the jaw or down the left arm, back pain, shortness of breath, indigestion, unexplained perspiration and/ or dizziness.

The longer the blockage remains in place, the more damage is caused to the heart muscle. Because the heart can't grow new cells, the damage can't be undone. And if enough cells die during the heart attack, the organ's ability to pump blood can diminish dramatically, leading to heart failure - or worse - acute cardiogenic shock. This was the case with Wolfson. In some instances, if the blockage is significant, or someone doesn't seek medical attention promptly, the heart's electrical system responsible for creating the heartbeat can short circuit, causing cardiac arrest, or sudden cardiac death. In other words, the heart attack sufferer dies unless the heartbeat can be restored.

That's why doctors stress the importance of seeking immediate medical attention. Time is muscle. The sooner you seek help, the better off you'll likely be. Getting the right care at the right time is a matter of life and death.

Wolfson understood what was happening to him on that April morning because he had been diagnosed with heart problems 15 years earlier. Once he recognized the signs, he knew he had to call an ambulance. Many people with chest pains try to make it to the nearest hospital on their own, or with the help of a loved one or friend. That's a big mistake.

Years ago, the primary job of an ambulance crew was to convey a patient to hospital. But today's ambulances are mobile medical units, staffed by specially trained paramedics who can begin the diagnosis and treatment of a heart attack as soon as they arrive at your door. In Wolfson's case, paramedics immediately did an electrocardiogram (EKG) to check for the electrical pattern of his heart attack upon arriving at the scene. The EKG was sent via BlackBerry to a cardiologist on call at St. Boniface Hospital who talked to the paramedics and directed further care, starting in the ambulance.

Dr. Roger Philipp, Director of the Cardiac Sciences Program's Heart Catheterization Laboratory, says transmitting an EKG from the field to a cardiologist is a major improvement in the treatment of heart attack patients because the cardiologist can confirm the heart attack. Then, while the patient is en route to hospital, a heart attack team is mobilized to provide the best care as soon as possible.

"This speeds up the process because the patient is then taken to St. Boniface's cardiac cath lab (a room specially equipped for performing complex procedures, such as angioplasty) for immediate treatment rather than a patient going to possibly a different hospital without a cath lab, then getting an EKG and then having to be transferred to the St. Boniface's cath lab," Philipp says. "Time is muscle. The heart attack can be stopped in less than 90 minutes, often in an hour, from the time the ambulance first arrives. This saves up to hours, which means less heart damage and a greater chance of survival."

"The gold standard from first medical contact to artery open is under 90 minutes," Tam says. "With the STEMI Protocol, we're achieving that target most of the time. In the old days of going to hospital first, that time target would be achieved only a quarter of the time."

And don't worry about false alarms, adds Philipp. "Let the paramedic and the cardiologist make that call," he says. "To do otherwise is to risk your life."

When Wolfson arrived at St. Boniface Hospital he was immediately taken up to the catheterization lab in the Bergen Cardiac Care Centre for an angiogram. Although he was diagnosed in the field, the angiogram - an X-ray picture of the heart artery - was required to give doctors the precise location and number of blockages causing the heart attack.

To do this, an X-ray dye is injected into the coronary arteries through a catheter. The catheter is guided by a soft-tip wire that is usually inserted through the femoral artery in the patient's right leg, and gently makes its way up to the heart. "It's like a railway track on which we can lead in the catheter. We put the thin wire up through the artery and the catheter will follow over that wire," says Carol-Anne Schulz, a nurse at the lab.

The dye shows where the blood is flowing and, more importantly, where it's not. Where there's a blockage, the flow of dye stops or becomes faint. Once the angiogram is complete, the cardiologist may discuss treatment options with a cardiac surgeon. If the blockages are extensive, bypass surgery is scheduled, sometimes within a couple of hours of the angiogram. In other cases, the blockages can be relieved through a procedure known as angioplasty.

"If it's a complete blockage from an ongoing heart attack, they'll usually go in and fix that right away with angioplasty," Schulz says.

In these cases, a deflated balloon is inserted up to the blockage along the wire in the artery using the catheter tube. The balloon is then inflated, opening up the artery and restoring blood flow. Mounted on the outside of the balloon is a stent, an expandable metallic mesh tube that is expanded by the balloon and keeps the artery open after the balloon is deflated and removed.

Wolfson had been through the procedure before when he had two stents implanted 15 years ago. On this day, he would undergo the procedure again.

In retrospect, Wolfson says he could have recognized sooner that he was heading for a heart attack. He had difficulty walking for any distance at all in the weeks prior to his heart attack. He was out of breath, and his symptoms got worse.

Tam says Wolfson was exhibiting all the signs of a crescendo angina, a condition in which pain becomes more frequent and intense or occurs with lesser degrees of exertion.

Angina is an episodic reduction in blood flow that often happens with physical exertion, which can, in some cases, be a warning of an imminent heart attack.

Today, Wolfson, still recovering from his heart attack, remains as vibrant and energetic as ever. At the photo shoot for this story, for example, he was full of stories and jokes: "Wish I had the account for all this camera equipment," the former salesman quipped while waiting for the photographer to snap his picture. He is grateful for the care he received, under the coronary care cardiology team, but singles out one nurse for making sure he didn't develop pneumonia. As part of her routine, she would regularly get Wolfson out of bed so he could stretch and prevent a build-up of fluid in his lungs. Tam says seriously ill heart attack patients are often at risk of secondary complications, including infection, while in intensive care. They are at higher risk of pneumonia if they require mechanical ventilation.

"The professionalism, the knowledge and the empathy were fantastic," Wolfson says.

Joel Schlesinger is a Winnipeg writer

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	About Wave Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books. Read the Summer 2010 issue of Wave