Heart attack Code

//Protocol for urgent action in cases of acute myocardial infarction

“Time is muscle. In heart attacks, there is a very clear link between the heart’s ability to recover and the amount of time that elapses before treatment: the longer the delay, the less cardiac muscle is preserved. Every hour is critical.” Dr. Ángel Cequier is the clinical director of the Department for Heart Disease at Bellvitge University Hospital. When a patient arrives at his unit within thirty minutes of the onset of heart attack symptoms, the most likely outcome is that the patient will be resting at home three days later. However, if the arrival is more than eight hours after the onset of symptoms, there is very little that can be done.

For heart attacks, the fight against time is a battle of life and death. In the most literal sense

For heart attacks, the fight against time is a battle of life and death. In the most literal sense. Acute myocardial infarction (AMI) occurs when the blockage of a coronary artery prevents blood from reaching a part of the heart. The diminished blood flow injures the muscle and the injury expands as long as the artery remains blocked. The best way to treat a heart attack is with immediate reperfusion methods. That is, unblocking the artery as quickly as possible so that the blood begins to circulate again. If several hours have elapsed, the extent of necrosis can affect the entire sector that depends on the artery. At that point, the damage is irreversible.

Basically, the prognosis for a patient with AMI depends on the urgency with which he or she is treated. The Catalan health service has found a way to buy time for heart attack victims: by reorganizing. “The most beneficial reperfusion therapy is primary angioplasty, which involves inserting a balloon into an occluded artery to restore blood flow. But this technique is done only in high tech centres. We needed to shorten the interval between the detection of a heart attack and doing the angioplasty, and that’s what we’ve done by implementing the Heart Attack Code.”

The Heart Attack Code (or AMI Code)

The Heart Attack Code is a protocol put into operation in Catalonia in June 2009. It involves a series of mechanisms that come into play when a patient making contact with any level of the health services network is suspected of having a heart attack. Ten referral hospitals were established for heart attacks and each was assigned to a specific geographical area. As a result, whenever a doctor takes the view that a patient is a candidate for immediate reperfusion, he or she automatically refers the patient to the corresponding area centre. The centre has an obligation to receive the patient and to return him or her to the original hospital or the one nearest home, once he or she has been treated and stabilized.

“The Bellvitge Hospital is the referral centre for the Southern Metropolitan Area, which covers roughly 1.3 million people. At night we also take on the Tarragona area. I think we are the centre on the Iberian Peninsula that treats the most heart attacks: between 500 and 520 a year. The Spanish Cardiology Society published an article on the impact of applying the Heart Attack Code in which it was shown that we have reduced the response time by an average of 50 to 60 minutes.”  And saving time, when we are talking about heart attacks, is equivalent to saving lives.

In addition, the protocol has saved money. “The cost of taking action is lower now than it was under the previous model. Before, patients underwent fibrinolysis—an expensive procedure—at the hospital where they were treated. Then on the next day, they were sent to us to do the angioplasty. Now we can skip the first procedure.” So the code has proven itself not only effective, but economical too. The initiative comes out of a consensus reached among the administrations, suppliers and the scientific community, who have also agreed to regular evaluation in order to uncover inefficiencies and fix them.

The Heart Attack Code Register

“When the protocol was put into operation, the health department of the Generalitat of Catalonia requested that we keep a register to log our actions. The tool, which started as a control mechanism, has been highly useful in identifying project weaknesses and acting accordingly. We doctors would perhaps like to see more clinical variables included, but from an administrative point of view it is a good register. Thanks to the register, we know where the patient came from, when he arrived, who identified him, which area he belongs to, who admitted him, who activated the code, how long it took to do so, how long it took to transfer the patient, what therapeutic decisions have been taken and what complications may have presented themselves.”

The ten hospitals in the network have an obligation to input all heart attack codes activated in their centres. They have to include clinical, epidemiological and administrative data, giving special attention to time intervals and health outcomes. This has helped to show, for example, that there is a greater delay in activating the code for a patient coming from a regional hospital than when identified in the field by emergency medical services (SEM, the Catalan acronym visible on ambulances). “It seems that the SEM raise the alarm immediately, while a patient at the hospital goes to the emergency room first, is perhaps referred to traumatology, is sent for an electrocardiogram, and so on.”

Positive trends have been detected as well. For example, the patients we are treating are in better shape than before the implementation of the protocol. “In the Cardiology Area, where we are the last resort, we generally received the patients in the worst shape. Some were even in cardiogenic shock. Now, by contrast, we can typically take action sooner. And we see fewer complications: before, we received patients many hours after their heart attack, already suffering heart failure. And we are discharging patients sooner too. The fact that the entire procedure is laid out in detail has helped us to act faster and smarter. The advantages of the code are beyond question. And we are realizing all of this from the data logged in the register.”

Incidence of cardiovascular disorders

Acute myocardial infarction is the leading cause of death worldwide. Some 30% of the deaths caused each year are due to cardiovascular illness. This can be peripheral vascular disease, which has a very low incidence, cerebrovascular disease or heart disease, which is the most common. “In Catalonia, we have between 420 and 450 heart attacks per million inhabitants each year. And the diagnostic methods and treatments are costly. If you add in the high degree of incidence, you can see why 15% of the resources of the Catalan health service are dedicated to treating these kinds of disorders.”

A healthy lifestyle, for example, can help to prevent a heart attack

In addition, the pathology is associated with ageing:  the older you are, the higher your likelihood of having it. “Just as our skin ages, our coronary arteries also age and the possibility of presenting AMI grows. Risk factors that can have an influence include whether the person is a smoker, has consumed toxic substances, suffers from high cholesterol, is a member of a family with a history of heart disease and so on. In Nordic countries, the incidence is between 600 and 700 heart attacks per million inhabitants, higher than in Catalonia: this figure can be put down to differing diet and habits.” While there are unalterable factors, such as age, sex—women are protected against heart attacks by hormones until they reach menopause—family history and genetic predisposition, specific coronary risk factors are alterable. A healthy lifestyle, for example, can help to prevent a heart attack.

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