Keeping the Beat

Dr. Louis Fink, medical director of the New England Heart Institute at Catholic Medical Center in Manchester, recently attended a conference that brought together heart specialists from around the nation. “There were reports on cutting edge technology,” he says. “There were sessions on critical issues of diagnosis and treatment. But there is still no silver bullet, no perfect pill for heart disease.”

“Without doubt,” Dr. Fink says, “we will get the best outcome, for individuals and for society, from prevention efforts.” The guidelines for prevention of heart disease are probably familiar to readers: systolic blood pressure under 120; weight within normal range; low density lipids below 80 mg/dL (cholesterol management); daily exercise; avoid smoking and diabetes. In other words, control your risk factors as much as possible.

“The message may be familiar,” says Dr. Fink, “but this is still a major focus. Too many people are not following heart health practices.” The older one is, the more important are these prevention practices. With age, he says, both the disease itself and the intervention (treatment) carries greater risk.

There are new diagnostic tools available, when risk factors and/or symptoms indicate need, though Dr. Fink believes that the “old-fashioned” exercise stress test is still a good beginning point. Coronary CT scans are used to reveal calcium deposits that reflect the extent of atherosclerosis, or calcified material in the arteries. Most heart attacks, however, are not caused by the hard, calcified plaque but by a chunk of soft plaque that breaks loose and blocks blood flow to the heart. Still, studies indicate that there is a connection between the amount of calcium and of soft plaque in coronary arteries

A procedure called CT or coronary angiography visualizes the soft plaque. A dye is injected into an artery, to trace the path of blood flow and identify blockages. A report on the use of cardiac scans was published by the American Heart Association in 2006. The expert panel concluded, “It may be reasonable” to measure atherosclerosis using a scan, for certain individuals who, based on personal risk profile, have a mid-range risk of heart attack. A risk factor profile will include age, gender, history of smoking, cholesterol readings, family history and systolic blood pressure with and without treatment.

Coronary calcium has become a topic of conversation among health-minded people. But a scan should not be seen as routine screening. “In the absence of symptoms or at least two risk factors,” says Dr. Fink, “there is no need to know your calcium score.”

Readers may have heard the phrase “door to needle” or “door to balloon” and wondered what it meant. The term refers to the time that elapses between the arrival of a patient experiencing acute myocardial infarction (heart attack) and the insertion of a balloon catheter to open the blocked artery. “Time is critical,” says Dr. Fink. “Reducing this time is literally a life and death issue.”

The American College of Cardiology and the American Heart Association have set a goal of 90 minutes for “door to balloon.” Hospitals around the nation are revising procedures, but fewer than one third have achieved this goal. Time is often lost in preparing for surgery and assembling the team of specialists. In a rural area, critical time is lost in transportation.

“We need to ask, how fast can the EMT reach the patient, how long will it take to reach the hospital,” says Dr. Fink. Time is gained if first steps can be taken in route. But again there are questions. “Are the emergency technicians certified to administer an electrocardiogram or clot-busting (thrombolytic) medication? Do they have the capacity for instantaneous transfer of information? Is the emergency vehicle equipped for these tasks?” Many emergency response systems are upgrading their services, but funding problems often delay this effort.

Many hospitals have designed communication systems to speed up response time. Each New England Heart Institute specialist has a fax machine at home, turned on 24 hours a day. Information about a patient from a hospital at some distance or from an emergency responder will precede the arrival of the patient. The cardiac team can assemble and prepare for the anticipated procedures while the patient is in route.

The New England Heart Institute has achieved the goal of treatment within 90 minutes in 92 percent of cases. This exceeds the 88 percent achieved by the “nation’s top hospitals,” as reported by the U.S. Department of Health and Human Services. The Department’s Hospital Compare Web site gives this and other information on several thousand hospitals. Two hospitals, one in Michigan and one affiliated with Duke University, have achieved door-to-balloon in 50 minutes.

A diagnosis of a heart condition is frightening, but does not necessarily lead to a heart attack. Arrhythmias (rapid or irregular heart beat), heart failure (blood is not pumped in sufficient amounts to nourish the organs) and cardiomyopathy (the heart muscles become weak) are conditions that usually respond well to treatment. Pacemakers, implantable defibrillators and new medications have made it possible for millions of people with heart disease to live productive lives.

Not far into the future, says Dr. Fink, genetic analysis will determine what drug therapies will be effective for you, the patient. Gene transfer therapy will assist myocardial regeneration — picture the damaged heart healing itself. Even so, he cautions, individual heart healthy living will remain the foundation of heart health. NH