A person suffering a heart attack in 1950 was rushed to the hospital, even though the only thing doctors could offer there was bed rest, watchful care and pain relief. Five decades later, heart attack treatments have expanded dramatically, but that rush to the hospital is still a crucial factor.

A heart attack is caused by the complete blockage of one or more of the arteries carrying blood to the heart. Typically the blockage occurs when a blood clot forms at a location where the artery is already severely narrowed by cholesterol-laden plaque. The crushing chest pain accompanying the attack is the heart’s signal that it needs oxygen; the sooner it gets it, the less extensive the damage to the heart muscle. About 50 percent of deaths occur in the first hour, before the patient gets to the hospital.

In addition to chest pain, symptoms of a heart attack include lightheadedness, sweating, nausea, shortness of breath and/or fainting. The pain is often described as crushing and unbearable–like an elephant stepping on your chest. But it may also be merely discomfort, fullness or squeezing and it may spread to the jaw, neck, shoulders, arms, back and upper abdomen. Some individuals, particularly women, experience only non-specific symptoms.
If you believe you’re having a heart attack, there’s no time to sit and second guess yourself. Within 10 minutes of the onset of symptoms, call an ambulance–or if you know that it’s going to take 30 minutes or more for an ambulance to get to you, have someone drive you to the nearest emergency department. Under no conditions should you drive yourself.

Chew an Aspirin Tablet
Even before the ambulance arrives, you can get treatment started by chewing an aspirin tablet. Aspirin inhibits the action of blood platelets and may be helpful until more powerful medications can be administered. It’s important, of course, to inform emergency medical staff that you have done so.

Treatment continues in the ambulance on the way to the hospital. In many cases, emergency medical staff are in direct contact by phone with the hospital and getting instructions from cardiologists who will be administering care. One recent study [American College of Cardiology, August, 2002] found an advantage in having ambulance crew administer the clot-dissolving drug reteplase (Retavase). The time required to begin hospital treatment was cut in half for patients getting Retavase in the ambulance.
At the hospital, an electrocardiogram (EKG) is performed to monitor the heart and verify the diagnosis. Once the diagnosis is confirmed, treatment can begin immediately.
The goal is to clear the blockage and restore blood flow to the heart as quickly as possible. Since the mid-1980s, this has been done effectively through use of thrombolytic or clot-dissolving medications such as streptokinase and tissue plasminogen activator (tPa).
Studies show that, when started soon after the onset of symptoms, thrombolytic medications restore blood flow for about 80 percent of patients, reducing damage to the heart and improving the chance of survival.

Following thrombolytic therapy, heparin may be injected for the next 24 to 48 hours along with aspirin and other medications such as beta blockers and ACE inhibitors
While this therapy is designed to dissolve the clot, it does not affect the underlying plaque that narrowed the artery in the first place. At a later time, balloon angioplasty or coronary bypass surgery may be performed to restore blood flow through the narrowed artery.
Since the mid-1990s, angioplasty (or sometimes even coronary bypass surgery) are frequently performed on an emergency basis as immediate treatment for a heart attack. The cardiologist inserts a balloon-tipped catheter into the artery and compresses the cholesterol-laden plaque against the vessel wall. In most cases, a wire mesh tube or stent is then implanted into the damaged part of the artery.

Studies comparing thrombolytic therapy and immediate angioplasty have found that they are about equally effective in preventing damage to the heart muscle. Angioplasty, however, is more likely to keep the artery open over the long term and prevent recurrent problems.

Timing Is Crucial
Although angioplasty is generally preferred, which treatment is chosen depends largely on timing and available facilities. Only about 20 percent of hospitals in the country can perform emergency angioplasty, and transferring a patient to such a facility before starting thrombolytic therapy is usually not advised.

Even when the facility can perform angioplasty, the decision is still a matter of timing. How far away does the cardiologist live? How soon can the procedure be initiated?
A Harvard study of more than 27,000 heart attack patients treated in 661 hospitals from 1994 through 1998 confirmed that time is of the essence. The hospitals represented a cross section–from small community facilities to large academic centers. The researchers found that a crucial factor influencing outcome was the “door-to-balloon” time–the time between the patient’s arrival at the hospital and the insertion of the balloon-tipped catheter. When that time exceeded two hours, the risk of death was doubled.
One factor influencing the door-to-balloon time is the skill of the cardiologist, and the study confirmed that mortality was 33 percent lower at hospitals where frequent procedures are performed–more than three each month.

The message is clear: if angioplasty cannot be performed promptly by an experienced team, thrombolytic therapy may be the best option. Research has demonstrated that the benefits of clot-dissolving therapy are greatest when it is administered early–within 90 minutes of the onset of symptoms or sooner. After initial treatment of the heart attack, the patient may later be transferred to another facility for angioplasty or coronary bypass surgery.
The odds of surviving a heart attack have improved dramatically since 1950 or even 1990. More than 90 percent of patients now go home after a brief stay in the hospital. One factor remains unchanged: the need to act fast.

REFERENCES:
“Endovascular Cooling System Safely Used in Patients,” Health & Medicine Week, December 10, 2001.
“Hope Springs Eternal for the Broken Hearted,” Chemistry and Industry, April 16, 2001.
The Johns Hopkins White Papers, Coronary Heart Disease, 2002.
Marilyn Larkin, “Speed Is the Key to Effective Heart-Attack Treatment,” The Lancet, February 5, 2000.
“Light-Weight Heparin Has Heavy-Weight Results in Heart Attack Treatment,” Heart Disease Weekly, May 19, 2002.
Beverly D. Lucas, Nora F. Goldschlager, Thomas Ryan and Nanette Kass Wenger, “Acute MI Treatment: New Therapies, New Directions,” Patient Care, April 30, 1999.
Mary Ann Moon, “Transfuse Elderly MI Patients,” Internal Medicine News, January 1, 2002.
“Prehospital Administration of Retavase Can Accelerate Important Heart-Attack Treatment,” Blood Weekly, August 22, 2002.
“Research on Heart-Attack Treatment and Public Education Efforts Are Getting the Message Across,” Harvard Heart Letter, November, 2000.