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Saving Time Saves Lives
A heart attack does more damage every minute it's left untreated, so in Edmonton they created a shortcut by starting treatment at the moment the paramedic arrives.
At a Glance
Who - Paul Armstrong is a senior cardiologist at the University Hospital in Edmonton and a professor at the University of Alberta. Dr Robert Welsh is Chair of the Vital Heart Response Program and Associate Professor at the University of Alberta. Dr Padma Kaul is Associate Professor at the University of Alberta.
Issue - Heart attacks can cause major damage to the heart in just a few hours. Doctors needed to find a shortcut that could reduce the typical 2-3 hour delay between symptom onset and hospital arrival.
Solution - Edmonton provided its paramedics with electrocardiogram equipment that could send readings to cardiologists, getting a diagnosis and treatment started often before the patient even arrived at the hospital.
Impact - Armstrong's method has shaved approximately one hour off the normal treatment time. In some cases, patients treated within an hour after symptoms start are spared any permanent muscle damage to the heart.
In a heart attack, time is the enemy; every minute without treatment means more damage to the heart and greater risk of death. A research team in Edmonton has found a novel way to advance care of the most deadly type of heart attacks, acute ST elevation myocardial infarctions (STEMI).
Dr. Paul Armstrong, senior cardiologist at the University Hospital in Edmonton and a professor at the University of Alberta looked to Europe for inspiration to ensure that heart attack patients received speedy care even before they arrived at the emergency department.
"My colleagues in France have had a well positioned pre-hospital system for a number of years," said Armstrong. "In fact before we adopted this over 9 years ago I actually went to Paris and met with some friends and colleagues, and actually rode in their ambulances and stood in their call center and explored their system. The difference between France and Canada is that French doctors ride in the ambulances, whereas in our system is we can't spare doctors to ride around in ambulances. So what we've done is devolve and delegate the care in a team system that is seamless."
Armstrong's experiment commencing in 2000, conducted in collaboration with Dr. Robert Welsh and others in Edmonton, trained paramedics to do a 12-lead electrocardiogram (ECG) of the heart. In this way, the earliest point of care could begin to address the problem immediately rather than just transporting the patient to a busy ER. Using a cell phone, the paramedics could send the results of the ECG to an on-call cardiologist's laptop to confirm the diagnosis.
When a positive STEMI result was identified, the paramedic would give a clot-busting drug, in appropriately-selected patients that would restore normal heart function in just minutes. "Time is muscle, and muscle is life. That's the algorithm that we work on," said Armstrong. If a catheter-based strategy, such as balloon angioplasty, was deemed more appropriate, such patients could be more quickly triaged to the hospital best-equipped to perform the procedure.
This work led to better treatment options for the city of Edmonton. It has also provided a new understanding of how ECGs can help health care professionals determine how long ago a patient's heart attack happened and the extent of damage that has already occurred in the heart. This information helps physicians determine how best to treat the patient. In fact, Armstrong has found preliminary evidence that will be followed up in future studies that treatment within the first hour after a STEMI heart attack can actually stop the irreversible damage to the heart muscle that makes heart attacks so deadly. With the help of Dr Padma Kaul, a new understanding of how women with heart attack access the acute health care system compared with men has also been discovered.
