By Kristin Eckland
This is the second in a series on chest pain and chest pain emergencies.
You’ve developed jaw pain and profuse sweating, and a sense of dread. You know something is wrong. Now what?!!
Well, that depends on where you are. If you are in a rural area, you may not have a lot of choices, so you will have to head to the nearest facility. But in a more metropolitan area, the choices you have may significantly change your treatment options and subsequent outcomes.
In the case of an acute heart attack, or acute coronary syndromes, as we mentioned in our previous post, “time is heart muscle.” Doctors have only a short window to treat coronary ischemia before permanent, irreversible damage is done. This is the underlying principle which guides the care of all patients presenting with chest pain syndromes (including atypical chest pain). Multiple large studies in several countries have demonstrated that better short-term care produces more likely long-term survival when the treatment is initiated within three hours of the onset of symptoms. These results were recently supported by one large Japanese study published in the May 2012 British Medical Journal.
The consistent results of these studies have led to the development of the American Heart Association (AHA) guideline recommending a “door to balloon” time of less than 90 minutes. This means that hospitals must see, triage and treat all patients with chest pain within 90 minutes, or less, with balloon angioplasty which is the gold standard for care. Failure to meet this criterion results in stiff penalties in compensation. These guidelines have been adopted around the world as the standard of care for reducing morbidity and mortality.
“Balloon angioplasty” is a procedure where a doctor threads a catheter through a vein in either the wrist, or the groin, to open a blocked artery in the heart. However, not all hospitals and clinics have angioplasty facilities, which are expensive to maintain and require an on-site interventional cardiologist and support staff. This is particularly true in rural areas, and to some extent, even in some larger cities in Mexico. For people in smaller communities, you may not have a choice of where to go. But for city-dwellers, choosing the wrong facility means a delay in treatment as the initial facility evaluates you, and then waits to transport you to another, better equipped hospital. (Reference a case study of this situation in our article, Heart Attack – a Woman’s Way.)
This is why it is important to know before-hand where to go if you suspect that you, or a loved one, is having a heart attack. It’s not as straight-forward as it sounds. Here in Mexicali, a city of 1.5 million residents, there are only four facilities with cardiac catheterization labs, and none of these are located in the large, public facilities.
Coronary Angiography
During this procedure, the patient receives sedation, but will remain conscious. A wire is then threaded from either a blood vessel in the wrist, or the groin, to allow access to the large central arteries, and the heart itself. After the wire is in place, a small plastic catheter or tube is positioned over the wire into the artery, and the wire is removed. Through this wire, the cardiologists can administer medications, and instruments to manipulate the heart and blood vessels.
The cardiologists then use the catheter to inject radio-opaque dye into the coronary arteries to visualize blood flow, which is called coronary angiography. Areas that are not seen well during this procedure are the areas of blockages known as coronary atherosclerosis.
In the cath lab with Dr. Leonardo Monge
Today, I visited the cath lab at Hispano Americano Hospital in Mexicali. I joined Dr. Monge and his business partner, Dr. Raul Aguilera in the cath lab for a scheduled coronary angioplasty and stent placement for a patient who had recently had a heart attack. This patient had received an emergency intervention the previous month, but had complained of continuing symptoms on exertion at a follow-up appointment.
After being brought to the cath lab, the patient was draped from head to toe. Dr. Monge quickly maneuvered the C-arm into place, and places the angiography catheter. Once he injects radio-opaque dye, we see that the patient’s previous stent has no obstructions, or thrombus. In reviewing the films, however, another large blockage in a different artery is seen and that is what Dr. Monge suspects is causing the patient’s current symptoms. Dr. Monge and Dr. Aguilera quick deploy another stent to the narrowed area, widening the artery to increase blood flow. The whole procedure takes about thirty minutes.
Afterward, the catheter is removed, and a heavy bandage is placed at the insertion site in the patient’s groin. After a brief recovery period, the patient will be admitted for overnight observation before returning home. The overnight stay is mandated because of the location of the catheter and the use of blood thinners for the procedure which create a risk of serious bleeding. Doctors and nurses will monitor the patient for several hours to ensure there is no evidence of internal bleeding, or any damage to the insertion site.
Post angioplasty
After staying overnight, the patient is discharged with several medications to help slow the progression of blockage formation, and to prevent the stents from becoming clogged. This component of treatment is critical, since angioplasty and stent placement are stop-gap measures for a continuing disease process.
Remember: There is no cure for coronary artery disease, but diet and exercise along with medications, angioplasty and surgery can make it manageable.
In our next article, we will discuss some of the medications used to treat coronary artery disease.