By Phil Galewitz
Palm Beach Post (Florida)
Copyright 2007 The Palm Beach Newspapers, Inc.
All Rights Reserved
DELRAY BEACH, Fla. — Mildred Wolfe was leaving her condo to go to a local flea market one morning earlier this month when she suddenly didn’t feel right. There was no chest pain, trouble breathing or nausea. She just felt “funny.”
So, she stopped at a neighbor’s. Within minutes, the 80-year-old hairdresser felt intense pain in her jaw and then vomited. Her neighbor called 911. Paramedics arrived, recognized Wolfe was having a heart attack and took her to Delray Medical Center.
Alerted by radio to Wolfe’s dire condition, the hospital’s emergency room staff was ready when she got there. Within minutes, she was wheeled into the hospital’s cardiac catheterization lab for an angioplasty to open a clogged artery. At that moment, Wolfe’s heart started beating erratically, signaling she was going into cardiac arrest.
It took doctors three tries with a defibrillator to shock her heart back to a normal rhythm. Then the medical team performed the angioplasty and inserted stents to prop open the artery. An hour later, she was recovering in the intensive care unit.
Wolfe was lucky for many reasons, including her decision seven years ago to live near a heart hospital. “I guess I was at the right place at the right time,” she said.
But the reason why she’s alive and recovering at home today, experts say, is that she received life-saving angioplasty within 45 minutes of arriving at the Delray Medical ER. That’s nearly twice as fast as the national average and better than the new 90-minute national standard for heart attack patients to get angioplasty. The standard changed last year from two hours.
The faster heart attack patients get angioplasty, the better their chance of survival and recovery, studies show. For patients who receive the procedure within the 90-minute window, the risk of death is reduced by 40 percent.
At an average charge of $45,000 per procedure, angioplasty is one of the most lucrative for hospitals. That’s led an increasing number in Florida to seek state permission to offer the procedure along with open-heart surgery. Because of the improved patient outcomes with angioplasties, hospitals today typically do four times as many of them as bypass surgeries to open clogged arteries.
Still, too often hospitals locally and nationally fail to conduct an angioplasty on heart attack patients in time.
* According to a study last year by the National Heart, Lung and Blood Institute, only one-third of U.S. hospitals were able to conduct angioplasties on heart attack patients within 90 minutes of a patient’s arrival.
* In Florida, about 62 percent of heart attack patients were able to get an angioplasty within two hours after arriving at a hospital, according to a federal report card that looked at care delivered from April 2005 to March 2006. The national average was 67 percent.
* In Palm Beach County and the Treasure Coast, hospital performance under the old two-hour standard varied dramatically. JFK Medical Center in Atlantis met the two-hour standard with 75 percent of patients. Delray came in at 70 percent. Meanwhile, Palm Beach Gardens Medical Center and Lawnwood Regional Medical Center & Heart Institute in Fort Pierce met the goal only about half the time.
Report cards speed change
The delays in overall treatment occur for many reasons, including delays diagnosing the heart attack, contacting the cardiologist and getting equipment and other medical personnel in place. Most of the delays occur at night and weekends, when angioplasty teams are less likely to be on duty.
But the new federal report cards that compare facilities’ heart attack performance have spurred area hospitals in recent months to take steps to improve speed of treatment.
Moreover, competition among them to provide heart care is fierce and growing. The number of local hospitals doing angioplasty and open heart surgery will rise from four last summer to seven by the end of this year.
More than 1.1 million Americans have a heart attack each year, and more than 200,000 of them die before they reach the hospital. Thousands more die because of delays in hospital care.
It’s been about four years since studies proved angioplasty works better than drugs in most cases to restore blood flow and ensure long-term survival.
In angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel in the arm or groin up to the site of a narrowing or blockage in a coronary artery. Once in place, the balloon is inflated to push the clogging plaque outward against the wall of the artery, restoring the flow of blood through it.
But angioplasty only works if it’s done during or quickly after a heart attack.
Delray Medical said nearly all its heart attack patients now get angioplasty within 90 minutes. To reduce the time, the hospital notifies its cath lab team immediately after a diagnostic test in the ER confirms a patient is having an attack. That way the team may delay doing a scheduled angioplasty so that it’s ready for the emergency.
Also, the hospital now lets its ER physicians put the cath lab on standby instead of waiting for a cardiologist.
Delray Medical sees about 15 to 20 acute heart attacks each month.
“The changes at the hospital have dramatically improved our response time,” said Dr. Robert Carida II, the cardiologist who did Wolf’s angioplasty.
He said Wolfe’s case illustrates the benefits of those changes. “If you are going to go into cardiac arrest, the cath lab is the place to be,” he said.
Dr. Eric Lieberman, chairman of Delray Medical’s cardiovascular committee, said the public reporting of heart attack treatment helped motivate the hospital.
“It’s like bringing home a report card to your mom,” he said. “You want it to look good.”
Team effort saves lives
Palm Beach Gardens Medical Center is working with the city’s fire-rescue department to speed its care to heart attack patients.
Using new communications equipment, city paramedics can now transmit the results of an EKG that’s done in the field directly to the ER, which can then relay the information directly to a doctor’s office. An EKG measures heart rhythm and can often provide the most telling sign that the patient is having a heart attack.
Sending the EKG to the hospital can ensure the test is being read by a trained doctor, not just a paramedic.
“The sooner we have the information the sooner we can get the troops into motion,” said Dr. Scott McFarland, medical director of Palm Beach Gardens Medical Center’s emergency department.
Like Delray Medical, the Gardens hospital also now allows its ER doctors to alert its cath lab to an emergency angioplasty rather than waiting for a cardiologist to review the case. The hospital has met with its doctors, nurses and technicians to increase awareness about the need for speeding patients to the cath lab.
“We just know the quicker a patient has an artery opened, the less heart muscle is lost,” McFarland said. About 10 patients a month come to the hospital with an acute heart attack and need emergency angioplasty.
Knowing the signs
The symptoms of a heart attack can include:
- Chest pain (often described as a crushing, squeezing or burning pain in the center of the chest and may radiate to your arm or jaw)
- Shortness of breath
- Dizziness or faintness
- Sweating
- Nausea
- Cold or clammy skin
- A gray or very ill appearance.
Sometimes there may be no symptoms, especially if you have diabetes. Women sometimes have different symptoms, such as a different kind of chest pain and/or abdominal pain.
If you are having a heart attack
- Call 911 immediately. Don’t try to drive yourself to the hospital.
- Take an aspirin.
- Don’t delay, hoping the symptoms will subside.
Saving time
Yale University researchers surveyed 365 hospitals and documented six time-saving measures that may save lives of patients with serious heart attacks:
- Letting ER doctors activate the catheterization lab and prepare it for angioplasty instead of waiting for a cardiologist to review a case and decide what to do (8.2 minutes).
- Establishing a one-call system so a central operator pages an angioplasty team instead of having ER staff hunt down phone numbers and individual doctors on call (13.8 minutes).
- Having the ER activate the cath lab when paramedics alert them that an electrocardiogram done in the ambulance shows the patient is suffering a heart attack (15.4 minutes).
- Expecting staff to be at the cath lab within 20 minutes of being paged (19.3 minutes).
- Having a cardiologist on site at all times (14.6 minutes).
Surviving heart attacks
Heart attack patients are more likely to survive if they can quickly get an angioplasty. Patients who wait more than 90 minutes are four times more likely to die than those who get the clot-busting procedure in less than 30 minutes.
The percentage of heart attack patients who got an angioplasty within two hours of arrival at a hospital from April 2005 to March.
United States: 67%
Florida: 62%
Delray Medical Center: 70%
JFK Medical Center (Atlantis): 75%
Palm Beach Gardens Medical Center: 50%
Lawnwood Regional Medical Center & Heart Institute (Fort Pierce): 48%
Note: The standard time period to get angioplasty for heart attack patients changed last fall to 90 minutes from two hours. Boca Raton Community Hospital and Martin Memorial Hospital in Stuart began offering angioplasty last fall, after the study was completed. For more information go to
Source: U.S. Centers for Medicare and Medicaid Services