Developments in cardiovascular disease research and treatment have been accelerating, as the American Heart Association’s 75th Annual Scientific Sessions (Nov. 17-19, 2002, Chicago, Ill.) focused attention on advances in treating this leading cause of death.

Confronting the worldwide cardiovascular epidemic, the AHA established a strategic goal in 1998 to reduce coronary heart disease, stroke and risk by 25 percent by the year 2010. Robert Bonow, president of the AHA, took stock of the developments toward this objective during his opening address, noting that “research and translation” have become a crucial challenge for every cardiologist. The benefits of advanced care from cardiovascular research depend on a fast and disciplined translation to the clinical level, ensuring that patients are treated properly.

Get with the program
For hospitals, Dr. Bonow noted the impact of Get With the Guidelines, an effort launched by the AHA in 2000 to reduce the risk of recurrent heart attacks. These proven secondary prevention guidelines address cholesterol and blood pressure lowering, counseling to stop smoking and referrals to exercise programs. All eligible patients should receive the appropriate care that these guidelines identify, yet many hospitals don’t bother to monitor or measure their adherence to this guide.

This attitude may change shortly, as a separate report on the subject of guideline adherence was presented by Eric Peterson, M.D. (Duke Clinical Research Institute). The study evaluated the care of more than 250,000 heart attack patients. Among the 1,247 hospitals that participated in the study, the ones that did the best and most consistent job of complying with 15 core processes (nine in the first 24 hours of the hospital stay, six at discharge) achieved real benefits for their patients, substantially reducing the risk of a second fatal heart attack during the hospital stay. The 8.3 percent risk at the best group of hospitals compared with a 15.3 percent risk at the worst. Dr. Peterson noted that the knowledge of guidelines by the hospital staff was not different, but leading hospitals have developed systems and processes to ensure that rigorous adherence is achieved. While physicians don’t universally accept the concept of standardized care, the distractions of a busy healthcare system should not be allowed to compromise the delivery of proven high quality care for any patient. In other words, knowledge is not enough — it requires systematic action, and doing it by the book pays off here.

Do hospitals need an on-site cardiac surgery program to back up M.D.s performing interventions in cardiac cath labs? No. And that is also the official position in the Guidelines for Percutaneous Coronary Interventions from the AHA/ACC.

And, if you should have an emergency that may require an angioplasty or intervention, now there are data supporting (on average) the selection of a hospital with a diagnostic cath lab without an on-site cardiac surgery back-up. The latest data come from the National Registry of Myocardial Infarction, presented by Tim Sanborn, M.D. (Evanston Northwestern Healthcare). Evaluating more than 25,000 patients for mortality risk and door-to-balloon times, the Registry Data showed markedly different speed in treating patients at centers with diagnostic cath labs only (104 minutes vs. 116 minutes). Sounding the common theme of “Time is Muscle,” Dr. Sanborn reminds everyone that speed in diagnosing and treating these patients appears to be more important than skill, at least based on the number of annual procedures performed. Many of these hospitals with the faster treatment times and no cardiac surgery on-site performed fewer than the recommended procedures, yet still had solid outcomes. Maybe this data will encourage researchers and hospitals to reconsider the old paradigm of only establishing cath labs in high volume locations, and to recognize that speed in treating patients has become the more challenging variable in treating these patients.

Frankly, the average door-to-balloon time of 104 minutes at these faster centers is still unacceptable, at least in my opinion. If a hospital can routinely and consistently get a patient from the front door into the cath lab in five minutes (an achievable goal that is becoming the standard at most of the specialty heart hospitals), then the door-to-balloon times fall dramatically, and outcomes should improve substantially. So, are the M.D.s at these hospitals smarter, luckier or just plain focused on delivering solid care?

While you should hope not to personally experience the local standard of care, now is a good time to learn more about your hospital, their adherence to guidelines and their standards of cardiovascular care. It’s becoming less important to have the latest tools and toys than to have a focused and systematic approach to healthcare, using what is already known and proven to work.

Doug Orr, president of J&M Group (Ridgefield, Conn.), consults with medical device companies in strategy and business development for emerging growth markets, notably radiology and cardiology. Comments and suggestions can be sent to dforr@aol.com.