On Door-to-Balloon Time: The Other Side
If a person is having an acute heart attack, we need to try to open the artery causing the heart attack as soon as possible. This can be done either by giving a clot-buster medicine or doing angioplasty and stenting. A recent article in the New England Journal of Medicine has drawn attention to a very important subject. This studied various factors that could cut the time it takes for a heart attack victim to get earliest possible angioplasty. I think most of these strategies other than that suggesting having a cardiologist in the hospital all the time can be put in practice. That will mean interventional cardiologists staying in the hospital on the day (and night) they are on call like they did during their training. It will be hard, as this practice will have the potential of dissuading the best talent from choosing interventional cardiology as a line of choice. But I think we can achieve time goals by smoothing the process at several other levels that were looked into.
There is a need to pay attention to another aspect of the issue. We are aware that some people, when they are being watched, are consumed by the thought of committing any mistakes. No, I do not think I will call it Hawthorne effect. The study published in NEJM has got a lot of well deserved ‘air time’. I think the following points also need to get attention:
- For an algorithmic approach to work well, clarity from point A to Z is very important. It should be made clear that this approach is for clear-cut heart attack with clear-cut ST elevation on electrocardiogram (EKG).
- The pressure to meet time goals can lead to over diagnosis of ST elevation heart attack, hence leading to unnecessary, expensive and sometime harmful procedures.
- Despite the need to make time goals, a diligent effort should be made to make the right diagnosis. We should follow World Health Organization (WHO) guidelines for the diagnosis of an acute heart attack. Out of the three features including typical chest pain suggestive of angina, typical EKG changes suggestive of an acute heart attack (MI), and blood test suggestive of an acute MI, two should be present to make diagnosis of an acute MI. Of course, there are odd presentations of an acute MI. But algorithmic approach to treating a disease does not work well for ‘Zebras’ of medicine.
- We should not feel pressured into over diagnosing heart attacks for the fear of missing a rare one with odd presentation.
- A careful, even if quick history and physical examination before heart cathetrization should remain an integral part of management. According to the prevailing wisdom, an early visit to the catheterization lab is the best option for heart attack victims with ST elevation on EKG. But this may not be the best option for an occasional patient on account of his or her wishes, significant co- morbidities etc. A diligent history and examination will help us unearth these issues.
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There is a need to pay attention to another aspect of the issue. We are aware that some people, when they are being watched, are consumed by the thought of committing any mistakes. No, I do not think I will call it Hawthorne effect. The study published in NEJM has got a lot of well deserved ‘air time’. I think the following points also need to get attention:
- For an algorithmic approach to work well, clarity from point A to Z is very important. It should be made clear that this approach is for clear-cut heart attack with clear-cut ST elevation on electrocardiogram (EKG).
- The pressure to meet time goals can lead to over diagnosis of ST elevation heart attack, hence leading to unnecessary, expensive and sometime harmful procedures.
- Despite the need to make time goals, a diligent effort should be made to make the right diagnosis. We should follow World Health Organization (WHO) guidelines for the diagnosis of an acute heart attack. Out of the three features including typical chest pain suggestive of angina, typical EKG changes suggestive of an acute heart attack (MI), and blood test suggestive of an acute MI, two should be present to make diagnosis of an acute MI. Of course, there are odd presentations of an acute MI. But algorithmic approach to treating a disease does not work well for ‘Zebras’ of medicine.
- We should not feel pressured into over diagnosing heart attacks for the fear of missing a rare one with odd presentation.
- A careful, even if quick history and physical examination before heart cathetrization should remain an integral part of management. According to the prevailing wisdom, an early visit to the catheterization lab is the best option for heart attack victims with ST elevation on EKG. But this may not be the best option for an occasional patient on account of his or her wishes, significant co- morbidities etc. A diligent history and examination will help us unearth these issues.
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posted by kc at 12:55 PM
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