Treatment for Heart Attacks Can Begin in the Ambulance

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May 23, 2000 -- Researchers in Canada say that more patients who suffer heart attacks should receive a life-saving treatment with clot-busting drugs before they even reach the hospital, especially if they live far from the facility.

Furthermore, they say, too many heart-attack victims delay getting any kind of care because they don't realize they are having an attack.

The researchers, whose article on the topic was published in the Journal of the American Medical Association, reviewed studies that looked at the survival of people who got the therapy -- called thrombolysis -- before reaching the hospital, in such places as an ambulance or mobile intensive-care unit, compared to those who got it at the hospital. Thrombolysis medications include tPA, which is also commonly given as soon as possible after people have had a stroke.

Led by Laurie J. Morrison, MD, director of research in the division of prehospital care at Sunnybrook and Women's Health Sciences Centre in Ontario, the researchers found that those who got the medication before hospitalization lived about 200 days longer than those who got it after arriving. They say this was especially important for patients who had to travel more than an hour to reach a hospital.

"My ultimate goal is to encourage people to think about this in a rational way," Morrison tells WebMD. Prehospital treatment can reduce deaths, she says, "and the impact where it will be felt is where the transfer is long, in rural communities"

Morrison says that health care providers in rural or remote communities should be able to perform this early treatment, given adequate training. "Prehospital thrombolysis is very expensive," she says. "There is a lot of time and training and education that is needed to maintain thrombolysis in the field."

She is conducting further studies to determine the value of early treatment with clot-busting drugs in an urban setting. The transit time to her own facility in Ontario, for example, averages around 20 minutes.

But another cardiologist tells WebMD that it would be impractical to set up systems to administer this treatment outside the hospital. "I think it is highly likely that outpatient therapy does confer some additional benefit," says David L. Pearle, MD, a professor in the department of medicine and director of the coronary care unit at Georgetown University Medical Center in Washington, D.C. But, he says, the actual benefit is relatively small, as shown in these studies.

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Prehospital treatment with clot-busting drugs is "extremely uncommon" today, even in urban areas, according to Pearle. He adds that many hospitals, including his own, have moved beyond this therapy. "Most of the more sophisticated hospitals prefer primary angioplasty," in which doctors use a balloon device to open the blocked blood vessel, Pearle says. "These studies are pretty old and this technique has not caught on."

Both Morrison and Pearle say heart-attack victims should receive the best treatment possible as quickly as possible, regardless of what that treatment might be. And that means knowing the warning signs.

"We nip away five or 10 minutes here and there, but the greatest delay is still with the patient, from symptom [beginning] to calling an ambulance or getting to an emergency room," Morrison says.

Chest pain is the heart-attack symptom that most people misinterpret, she says, adding that it's not always recognizable pain. Any discomfort, feeling of pressure, or tightness should not be chalked up to stomach upset or muscle strain. The sensation can be intense or fairly mild, and it can come and go.

"People say, 'Oh, I have gastric burning, or my ulcer is acting up,'" she says. "The nature of the pain is not as important as the appreciation that you have some discomfort. We say anything above the belly button up to the jaw" could be indicative of a heart attack and should not be ignored.

"When you are having a heart attack, time is of the essence for all interventions," she adds. "Even if they don't get thrombolysis, they might be a candidate for something else" that also needs to be administered or undertaken rapidly.

Adds Pearle, "The central message is to get there as quickly as possible."

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