Article By: Dr Ernest Madu & Dr Paul Edwards - READ ORIGINAL ARTICLE
We have moved from flip phones to smartphones in most areas of life and must do the same in health care and heart care.
Chest pain is an umbrella terminology that cardiologists use to describe the many variations of discomfort patients may feel in the chest area that may signal a heart attack, an unstable blockage in the heart vessels, or other more uncommon forms of vascular catastrophe. This often includes chest tightness; heaviness in the chest; sharp or dull aches in the chest; an uncomfortable feeling in the chest that fails to go away, often waxing and waning; and, of course, frank, unmistakable chest pain.
In some patients, chest pain may feel like abdominal discomfort associated with bloating, nausea, or vomiting. Sometimes, these symptoms may be associated with other complaints including shortness of breath, palpitations, sweating, dizziness, or fatigue. In classical chest discomfort from heart attacks, patients describe an “elephant sitting on my chest”, profuse sweating and a feeling of “impending doom”.
Unfortunately, most heart attacks don't arrive blazing with characteristic presentation that make the diagnosis certain, simply based on the presentation. Many patients with heart attacks will have symptoms that are suggestive but not confirmatory and so must rapidly undergo specific diagnostic evaluations to make a diagnosis and proceed with treatment.
In patients with heart attack or unstable coronary disease, time to intervention is critical. Heart muscles die every minute of a heart attack and could lead to, at worst, death, or at best, irreversible damage, long-term complications, and a severely shortened life expectancy. Rapid diagnosis and immediate intervention save lives and restore normal health, free of complications and long-term disability from heart failure and other sequelae.
It is a no-brainier, therefore, that every chest pain must be treated as an emergency until proven otherwise. Denial is not therapeutic and ignorance is not curative. Speedy diagnosis and immediate intervention are the international standard of care and best practice supported by thousands of peer reviewed published research. That is what we do at the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. That is how thousands of lives are saved each year.
The choices we make can kill or cure; ignorance is not a solution and could be deadly.
We will use two recent patients seen at HIC to illustrate the problem.
Mr J is a 58-year-old businessman who presented to HIC with complaint of “uneasy feeling in the chest and abdominal discomfort”. He had seen a doctor who prescribed antacids for him, but he claims that they “help sometimes”. Not feeling so well, he went to an outlying hospital where he said, “ECG and everything was done” and was assured that everything was okay.
Based on his risk profile and clinical presentation at HIC, we were concerned about acute cardiac event and so recommended an ECG, echo, and cardiac enzymes to be done immediately. He was reluctant to comply because in his mind “everything was already done” at the other hospital, when in reality not much had been done. Ultimately, he agreed to have an echo which showed a large anterior wall motion abnormality and labs showed high cardiac enzyme level, all consistent with an evolving major heart attack.
We recommended to proceed immediately with an angiogram and possibly a stent in the involved vessel. He felt we were moving too fast and preferred to “wait and see”. He ultimately discharged himself against medical advice and died at home three days later. Heart attack is not a joke. It is one of the most serious health conditions and can kill quickly if mismanaged.
Mr T is a 65-year-old who started feeling chest discomfort with profuse sweating and light-headedness. He felt he was “about to die”. He was rushed to HIC and arrived at about 1:00 pm (within two hours of his initial symptoms). Our team on 24/7 coverage immediately determined that he was having a major heart attack. He accepted our recommendation to move quickly. His coronary angiography showed 99 per cent blockage of the major heart vessel and a stent was placed. His procedures, including stent placement, were completed within 65 minutes of arriving at HIC. His heart function was restored. He is alive and well today.
Two patients with similar conditions but with two dramatically different outcomes because of the decisions made. One family is left to deal with immeasurable grief and loss because of an uninformed decision to delay treatment.
Door-to-balloon time (D2B) refers to the time it takes for heart attack victims to receive a treatment called balloon angioplasty from the moment they walk through the hospital doors. Ideally, heart attack victims should be set and ready to undergo balloon angioplasty within 90 minutes of walking through the hospital door, if not sooner. This procedure is most effective within the 90-minute time frame before permanent damage to the heart has occurred.
At HIC, we have been able to accomplish a mean door-to-balloon time of less than 65 minutes when structural obstacles do not impede speed of care delivery. This should be the norm to which we should all aspire. It is imperative, therefore, that the community and all stakeholders understand the current body of evidence in acute heart care and work collaboratively to resolve the friction points that delay, and ultimately deny, care to thousands of ordinary citizens resulting in unwarranted loss of lives and increased disability. There is also an impact on the national economy when citizens are lost or disabled in their most productive years.
Unfortunately, practising high-level cardiovascular care, based on the evidence, is not always easy in an environment where the health-care ecosystem is asymmetric and uneven, quality is not measured, resources are limited, and health literacy is suboptimal. The frictions in the health-care services value chain often lead to misguided decisions by patients and other stakeholders, resulting in delayed treatment and catastrophic outcomes for patients and families.
Many patients in Jamaica still delay presentation to the hospital following symptom onset because, culturally, tea or ginger has been assumed to be helpful when they have discomforts that may, in fact, represent an evolving heart attack. For some patients and stakeholders, it is simply an economic issue, and delaying treatment can be thought to delay or limit expenditure.
In some instances, structural deficits impede rapid access since many providers and facilities lack the infrastructure or human capital to consistently provide rapid intervention and treatment in all cases of chest pain or heart attack. Chest pain is a 24/7 and 365 days a year issue. In many facilities, out of practical necessity, speedy response to chest pain or heart attack is not the norm. This anomaly, which is inconsistent with international best practices, has become normalised in the minds of many because it appears to be the dominant practice pattern. But, should this delay be the case? The answer is an emphatic, no.
We have an obligation to our patients to continue to strive to achieve best practice standards based on the evidence, irrespective of structural barriers. While we acknowledge our socio-economic and other structural impediments, the objective should be to find creative mechanisms to overcome them and to leverage resources within the health-care ecosystem to improve the access, quality, and speed of intervention in acute heart care.
Tradition vs standard of care
In Jamaica we often equate tradition with standard, especially in health-care service delivery. This is wrong. They are definitely not one and the same. Tradition is often an outcome of knowledge and resource. As knowledge and resources improve, traditions evolve.
Once upon a time, we relied on Motorola flip phones to make phone calls and typewriters to prepare documents. We wrote letters and waited weeks for a response. Now we rely on computers to prepare documents (even on our phones, like this column). Then we got smartphones with WhatsApp and other platforms for instant messaging.
We no longer travel by ship to distant lands – we fly. Space travel is now more imminent. The old “traditions” have given way to new and improved standards based on knowledge and resource availability. Why then is there an expectation that health care or heart care must remain in the antiquated bed rest-and medications-only tradition, despite the availability of new and improved techniques and technologies that allow for speedy response to save lives. We have moved from flip phones to smartphones in most areas of life and must do the same in health care and heart care.
The fact that the appropriate infrastructure and personnel are not yet universally available in Jamaica is insufficient reason not to aspire to make it a common reality. Before HIC arrived in Jamaica in 2005, simple cardiac diagnostics, like echocardiogram, were not widely available. Waiting time for an echo could be as long as three months and longer in the summer when the few available cardiologists went on vacation. We initiated a cardiovascular technician training programme to introduce echo technicians as part of the heart care team.
HIC also inspired many young doctors to pursue a career in cardiology. We are proud to have contributed to improving access. Echocardiograms are now widely available in Jamaica and waiting time has been reduced to less than one day in most parishes. This is more consistent with international best practices and standard of care. This is what progress looks like.
In nearly 20 years, no one has ever died on the table at HIC undergoing angiograms or angioplasty. Our procedure-related major complication rate is exceptionally low. Our cardiovascular surgery mortality rate is zero. Despite the structural impediments and other barriers, we are committed to continue in our quest to make acceptable standards of cardiac care more consistent with international best practices.