Maryland health officials are considering a plan that would rush heart attack patients to designated cardiac centers rather than the nearest hospital. These centers would provide emergency angioplasty -- a procedure in which a balloon-tipped catheter is eased into a clogged artery to clear a blockage -- regardless of whether they have the capacity to offer open heart surgery if something goes wrong.
Currently, if the closest hospital does not have cardiac surgery capacity, the patient may be treated with clot-busting drugs, which a decade's worth of research shows are about 30 percent less effective than angioplasty at saving lives, according to a recent article in the medical journal The Lancet.
Last month, a Maryland Health Care Commission advisory panel recommended that the state establish such a system, similar to a model that Boston implemented earlier this year. But just how well the idea will travel is open to question.
The central problems: ensuring access and quality. Not every area is like densely populated Boston, home to three medical schools and some of the world's best hospitals. Seven of Boston's nine emergency departments offer 24-hour angioplasty. By contrast, Maryland's 10,000 square miles of urban, suburban and rural communities are served by 50 acute care hospitals, 18 of which offer around-the-clock emergency angioplasty. But only nine of them do so with surgical backup facilities, and some of these are located an hour's ambulance ride from patients.
To implement the cardiac center concept in Maryland, the state would have to change its rules to allow smaller hospitals without heart surgery units to perform emergency angioplasty, says the Maryland Health Care Commission panel.
The plan presumes patients won't face complications from angioplasty and require emergency open-heart surgery. Increasingly, some cardiologists say that's a safe assumption. In 2000, only 0.14 percent of angioplasties triggered the need for an emergency bypass, according to a Cleveland Clinic study published last year, down from 1.5 percent in 1992.
Pamela W. Barclay, deputy director for health resources for the Maryland commission, finds the numbers persuasive, although she allows that not all experts are yet convinced. "It is an issue that a lot of states are struggling with," she said. The commission expects to take up the matter in May.
Surgical backup is just one problem. Numerous studies show that emergency angioplasty saves lives only if done quickly by an experienced team of doctors, nurses and technicians. Not every hospital can guarantee that, said Thomas J. Ryan, a professor at Boston University Medical School who helped develop national angioplasty guidelines.
"My worst fear is that we are opening a Pandora's box and every institution that can buy the equipment will decide to get into it," said Ryan. "It's important for the medical community to do this the right way."
Cost is another tricky issue, particularly at a time of state budget constraints. Some advocates say the cardiac center approach would save money, since angioplasty often allows patients to avoid expensive tests and leave the hospital earlier. Critics say such savings could be outweighed by the cost of starting and staffing new EMS networks and providing care for patients who might have otherwise died.
Arthur Levin, director of the Center for Medical Consumers, a nonprofit advocacy group based in New York, echoes the Pandora's box concern. The push for emergency angioplasty, he argues, may represent a case of doctors' rushing too quickly to adopt "the latest and the newest," he said. "If [angioplasty] is now the standard of care, it creates significant problems. How are you going to deal with all of these logistical issues?"
Piece by piece, it seems. In Virginia, some individual hospitals and groups are beginning to develop emergency angioplasty programs, but no statewide triage plan exists. In Fairfax County, doctors at any hospital can call a 24-hour number to arrange an ambulance transfer to Inova Fairfax Hospital, the 750-bed Falls Church teaching hospital that is equipped with full emergency cardiac surgery facilities. Next year, Inova Fairfax is scheduled to open the 150-bed Inova Heart Institute, a freestanding building that will house six operating rooms and seven catheterization laboratories. Two other metro area hospitals in Virginia with full cardiac surgery units are Inova Alexandria and Virginia Hospital Center in Arlington.
Doctors at the University of Virginia Medical Center in Charlottesville, who have set up a similar heart attack "alert" system, are working with local rescue squads to set up cardiac triage.
Doctors at the 59-bed Carilion Giles Memorial Hospital in western Virginia town of Pearisburg fly some heart attack patients out for angioplasty. On the other end of the state, at the 67-bed Riverside Tappahannock Hospital, administrator Liz Martin said officials there prefer to do emergency angioplasties on site rather than transfer patients out. They are closely watching the debate over surgical backup.
"It's on our radar," Martine said.
Maryland seems well poised to deliver the service statewide. The state's Emergency Medical Services (EMS) program already designates specialty emergency centers for several conditions, including burns, head and eye injuries, and pediatric emergencies.
Nine Maryland hospitals operate cardiac surgery units -- including Prince George's Hospital Center in Cheverly and Washington Adventist Hospital in Takoma Park. Another nine -- including Holy Cross Hospital in Silver Spring, Shady Grove Adventist Hospital in Rockville and Suburban Hospital in Bethesda -- began offering emergency angioplasty without surgical backup in 1996 as part of a Johns Hopkins University School of Medicine study. The Hopkins experiment, which included a formal training program for hospital staff, concluded that the hospitals performed the procedure safely. The state recently approved a cardiac surgery unit for Suburban Hospital, which is expected to be functional within a year.
For metro-area Maryland, the numbers translate this way: Out of a universe of 13 hospitals, two now have full cardiac surgery units, another is slated to come on soon, and two have waivers to offer emergency angio without surgical backup. If new regulations were to go through, officials don't expect they would bring quick changes in those numbers.
The four largest District hospitals -- Washington Hospital Center, Georgetown University Hospital, George Washington University Hospital and Howard University Hospital -- all do emergency angioplasty with surgical backup. Sibley and Greater Southeast don't perform the procedure. Providence Hospital uses clot-busting drugs on some patients and sends others out for angioplasty, depending on their condition and how quickly they can arrange a transfer.
But administrators of the District's EMS program say its system is too overtaxed to consider delivering heart attack patients anywhere except the nearest hospital that is accepting patients at the moment. Before the system can implement cardiac triage, said medical director Fernando Daniels, it must cope with closed emergency rooms and the shutdown of D.C. General Hospital
The same goes for Northern Virginia. "We're lucky if the [emergency departments] are open at all," said Melinda Duncan, director of the Northern Virginia EMS Council, which coordinates area services for the state.
In Boston, access is not an issue. From the Caritas Carney Hospital in working-class Dorchester to legendary Massachusetts General Hospital at the foot of Beacon Hill, no city hospital sits more than 10 or 15 minutes away from another.
As evidence supporting angioplasty over clot-busting drugs known as thrombolytics piled up in recent years, practices changed accordingly.
"We haven't given thrombolytic drugs since the mid-1990s," said Joseph P. Carrozza, chief of interventional cardiology at Boston's Beth Israel Deaconess Medical Center, the 530-bed Harvard Medical School teaching hospital that was one of the firstin the nation to adopt emergency angioplasty as the standard of care.
The advantage of angioplasty is speed. When fatty deposits build up or suddenly break off in the coronary arteries, they can block blood flow to the heart. A heart attack occurs when the oxygen-starved organ begins to shut down. Drugs can take an hour or more to fully dissolve the blockages. Angioplasty blasts through them, saving more of the heart muscle by instantly restoring blood flow.
Over the past 10 years, research confirmed what the doctors at Beth Israel and elsewhere were seeing. Based on the most recent data, about 5 percent of patients who have a complete blockage cleared by angioplasty die, compared with 7 percent of those who get drugs. In other words, for every 1,000 people who get angioplasty instead of drugs, about 20 lives are saved.
This was not lost on Boston paramedics. The vast majority of patients complaining of chest pain are not having heart attack, but the Boston squads are trained and equipped to do electrocardiograms right in the ambulance. That allows them to identify the roughly half of all heart attack patients who qualify for angioplasty. Traditionally, they took them--and all the others--to the nearest hospital. But that didn't always seem to be the best choice, especially when some heart attack patients didn't qualify for drug therapy, said veteran paramedic John Gill.
"You would bring a patient to a hospital and then watch as [hospital staff] made arrangements to transfer them to a hospital that does angioplasty," he said, shrugging. He couldn't help ask himself, "Did you just lose a half an hour?"
So, Boston ambulances carrying heart attack patients began speeding past the two hospitals without angioplasty -- Caritas Carney and Faulkner. In 2000, when the smaller hospitals complained that paramedics were making life-and-death decisions, Peter Moyer, the EMS medical director, came to the crews' defense.
"I didn't think it was fair to call the paramedics cowboys when medical practice was marching forward," he said. "We have to keep up."
It took more than two years, but late last year the Boston EMS, the city's hospitals and the state Department of Health agreed to a formal cardiac triage system -- and then only as an experiment. The state plans to monitor the program closely to make sure it is working.
To make the heart atttack center concept work, each community is going to have to come up with its own solution, said Thomas Aversano, a Johns Hopkins cardiologist and one of the major players nationally in this debate. He conducted some of the key studies of emergency angioplasty and advocates expanding access -- carefully. Triage will work in some areas, he said, and other communities will need to open new units. Finally, in areas where EMS services can't identify appropriate patients, some hospitals will have to set up transfer programs rather than angioplasty programs, he said. And, all of them will need close scrutiny.
"The answers to these questions are going to be very regional," said Aversano. "There is not going to be one size that fits all. I think access can be expanded, but it has to be done in the right places in the appropriate way."
Tinker Ready is a freelance health and science writer based in Cambridge, Mass. She writes regularly for the journal Nature Medicine.