Speeding Up Emergency Angioplasties

With a heart attack, speed counts. The guy who shows up at the ER entrance complaining of chest pain very likely dawdled for an hour or two at home before reluctantly letting his wife call 911 (you know who you are), and now the ticking of the clock is more of a countdown. For every half-hour delay in treatment, the odds that the man will be alive a year later worsen by about 7.5 percent. He needs to be rushed to the cath lab for an emergency angioplasty to reopen his blocked coronary arteries.

Whoa, say many hospitals. First the ER physician has to get permission from a cardiologist. And that's one reason that most hospitals don't come close to meeting the goal, set by heart organizations in 2004, of getting an angioplasty balloon into heart-attack patients within 90 minutes of the time they arrive at the ER. The cardiologist on call might be out of cell range or otherwise unavailable. Even after being contacted, the heart doc has to agree to tell the angioplasty team to get ready.

You can see why hospitals would have a rule about calling a cardiologist first. This specialist knows better than any other whether an apparent heart attack is for real. Why gear up the lab for a procedure that could unnecessarily put the patient at risk–no procedure is completely safe–and is expensive to boot?

But now comes a new pair of studies with a strong counterargument. One makes a solid case that emergency physicians are just as good as heart doctors at diagnosing a heart attack. (At the large hospital studied, ER docs with the freedom to diagnose a heart attack and activate the angioplasty team on their own picked up all 172 heart attack patients who came in during a 13-month period.) The other found that letting ER docs at another big hospital make the decision to alert the cath team slashed the average "door to balloon" time to 91 minutes from the former 131. The studies are being published online today in the Annals of Emergency Medicine.

These are persuasive studies–I hope they will be heeded. I think the message is sinking in. Last November, I reported a presentation at a major American Heart Association meeting with much the same message in different dress. The presentation, later released in the New England Journal of Medicine, ticked off a handful of ways to speed patients to the angioplasty table–not only giving ER physicians the authority to say "Go," but also letting emergency personnel outside the hospital call the cath lab if an ECG indicated a heart attack (saving 15 minutes). Requiring cath lab staff to get to the hospital within 20 minutes would lop off almost 20 minutes.

I don't think most cardiologists would hesitate for a second to give ER docs the ability to save lives in this way. The question is whether hospital administrators will go along. The evidence seems overwhelming. I'll be watching with interest.