Study: Heart attack treatment should start in ambulance
Cardiologists have long known that the faster they treat a heart attack once a patient arrives at the hospital, the better the patient’s outcome. But there have been more questions than answers for how best to manage patients’ care during that window of time between the onset of symptoms and their transport to the hospital.
Should ambulance services transport heart attack patients to the nearest hospital? Or should the ambulance travel to a hospital that specializes in the care of heart attacks, even if the facility is farther away? What if treatment was initiated before the patient even arrived at the hospital? How would that affect patient outcomes?
Physician researchers at Medical School have spent years studying these questions and revealed their answers in an Oct. 16 article published in the Journal of the American College of Cardiology.
Dr. Richard W. Smalling, professor in the Division of Cardiology and holder of the $1 million James D. Woods Distinguished Chair in Cardiovascular Medicine, led a pilot trial that analyzed treatment given in the ambulance followed by urgent coronary intervention.
Between September 2003 and January 2006, 73 patients were enrolled in the trial. One group of patients was given a drug cocktail, including a half dose of a clot buster, prior to arrival at Memorial Hermann – Texas Medical Center. This was followed by a second dose of clot buster and treatment in the coronary care unit.
Another group was given the same drug cocktail – a half dose of reteplase (clot buster), plus the blood thinner, heparin, and oral aspirin. Upon their arrival at the hospital, patients in this second group where immediately taken to the cardiac catheterization lab for angioplasty, or percutaneous coronary intervention (PCI), to reopen blocked arteries.
A third group of patients was ineligible for the pre-hospital fibrinolytic (clot busting) treatment, and the fourth group included patients who were transported by emergency medical systems units that were not participating in the clinical trial. These two groups of patients were treated with angioplasty in the catheterization lab.
The findings overwhelmingly supported that a half dose of the drug cocktail, followed by an interventional procedure in the catheterization lab was the most effective heart attack treatment. The study also demonstrated that the drug cocktail did not increase a patient’s risk of bleeding.
By the time they were taken to the catheterization lab, 82 percent of the patients who received the reduced-dose fibrinolysis had an improved blood flow grade, compared with less than 40 percent of the patients who were treated with angioplasty alone.
Almost 70 percent of the patients who received the reduce dose experienced a full restoration of blood flow to the heart following angioplasty, compared with only 22 percent in the groups that went straight to the cath lab without pre-hospital medication.
Also, almost 70 percent of patients who received the full dose and were scheduled to go to the coronary care unit for further care required angioplasty earlier than scheduled to resolve their chest pain and stop the heart attack.
“This suggests that PCI immediately after pre-hospital fibrinolysis should be the standard of care,” said Smalling, director of interventional cardiovascular medicine at Memorial Hermann – TMC.
“Taking a patient to the closest hospital and only giving them fibrinolysis doesn’t get the job done. Taking a patient to a PCI center for primary PCI, without getting pre-hospital clot busting treatment, delays reopening the heart attack
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“This suggests that PCI immediately after pre-hospital fibrinolysis should be the standard of care,” said Smalling, director of interventional cardiovascular medicine at Memorial Hermann – TMC.
“Taking a patient to the closest hospital and only giving them fibrinolysis doesn’t get the job done. Taking a patient to a PCI center for primary PCI, without getting pre-hospital clot busting treatment, delays reopening the heart attack
-M. Raine
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Geriatric Education Grant Will Focus Expertise on Vulnerable Elders
Dr. Carmel Dyer, director of the Division of Geriatric and Palliative Medicine, is principal investigator for a new $650,000, three-year grant from the U.S. Department of Health and Human Services to form a Geriatric Education Center that will concentrate on vulnerable elderly people.
Dr. Sharon Ostwald, professor in the Center on Aging at the School of Nursing, is co-principal investigator of the center’s multi-disciplinary grant, which includes five schools within the UT Health Science Center at Houston.
The new center will be one of 48 in the country.
“It’s very exciting to be part of a national effort to educate members of different disciplines about geriatric issues,” said Dyer, the Roy M. and Phyllis Gough Huffington Chair in Gerontology. “Beyond that, our center will be unique because of its focus to go beyond general geriatrics to the most vulnerable individuals.”
Along with the Medical School and Nursing School, the center will include the UT Dental Branch, the UT School of Public Health and the UT School of Health Information Sciences. Faculty from the University of Houston’s schools of pharmacy and social work, as well as occupational and physical therapists at Texas Women’s University, also are included in the grant.
The center will train faculty, students, and practicing professionals to provide the knowledge and skills to maintain healthier communities for the most vulnerable older people. The goal is to address issues of safety, medical care, economic and social support, and disaster preparedness for this growing, fragile segment of the population.
“Elder abuse and exploitation remain largely hidden and undiagnosed problems in the elderly population,” said Ostwald, the Isla Carroll Turner Chair in Gerontological Nursing. “Our intent is to train health care professionals and others so that the problem is recognized early and treatment can be initiated, so elders can live in safer, healthier environments.”
“Increased community organization and sensitization of health care teams are needed to assess vulnerability and recognize and intervene in cases of elder mistreatment and elder self-neglect,” said Dyer, author of a recent article on elder self-neglect in the Journal of the American Medical Association.
In the community, the Geriatric Education Center will provide continuing education to adult protection staff, nursing home inspectors, staff and volunteer long-term care ombudsmen, local police and sheriff departments, financial planners, guardians, elder-law attorneys, and family caregivers – all of whom are in unique positions to identify and refer vulnerable elderly into the health care system.
-D. Mann Lake
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Rheumatologists discover genes related to disabling form of arthritis
Work done in part by Medical School researchers has led to the discovery of two genes that cause ankylosing spondylitis, an inflammatory and potentially disabling disease. The findings are published in the Oct. 21 online edition of Nature Genetics, a journal that emphasizes research on the genetic basis for common and complex diseases.
Dr. John Reveille, professor and director of the Division of Rheumatology and Clinical Immunogenetics, in conjunction with Dr. Matthew Brown, professor of immunogenetics at Australia’s University of Queensland, led research done by the Triple “A” Spondylitis Consortium Genetic Study (i.e. the TASC or Australo-Anglo-American Spondylitis Consortium).
The international team of researchers worked with investigators from the British Wellcome Trust Case Control Consortium, and together they made the genetic discovery.
Reveille, chief of rheumatology at Memorial Hermann – Texas Medical Center, said the discovery of genes ARTS1 and IL23R brings the scientific community two steps closer to fully understanding ankylosing spondylitis or AS, a chronic form of arthritis that attacks the spine and also can target other joints and organs in the body.
“We’ve long known that the HLA-B27 gene accounts for 40 percent of the overall cause of AS,” said Reveille, the principal investigator of TASC. “Now we have found two new genes. Together with HLA-B27, these genes account for roughly 70 percent of the overall cause. That means we’ve almost nailed this disease. Within the next year, I predict we will have identified all the genes that play a role in this insidious disease. There is more exciting news to come.”
The recent discovery is based on work from the largest and most comprehensive genome-wide association scan conducted to date. In this part of the research project, investigators were searching for genetic information related to AS, as well as autoimmune thyroid disease/Graves’ Disease, breast cancer, and multiple sclerosis. Reveille, the George S. Bruce, Jr. Professor in Arthritis and Other Rheumatic Diseases, said the most significant findings were in AS, a disease that generally strikes patients in their teens, 20s, or 30s.
ARTS1 and IL23R show a new pathway of causation, Reveille said, and this could lead to new therapies for the arthritic condition, which can cause a complete fusion of the spine, leaving patients unable to straighten and bend.
The identification of the two new genes also could help physicians identify patients who are at the highest risk for developing AS.
“For example, if you have a family member with AS, a simple blood test would be able to tell us if you are also at risk,” Reveille said. “We could offer screenings for people with back pain. In the past, the HLA-B27 test was all we had. Now we potentially have more tests.”
The research done by Reveille and his colleague Xiaodong Zhou, M.D., associate professor of medicine in Division of Rheumatology and Clinical Immunogenetics, was supported in part by the Center for Clinical and Translational Sciences (CCTS) at The University of Texas Health Science Center at Houston.
The Spondylitis Association of America (SAA) oversaw the nationwide recruitment of patients and families for the study.
“This is the most significant breakthrough in AS genetic research since HLA-B27 was uncovered 34 years ago, and SAA played a significant role in making the study possible,” said SAA Associate Executive Director Laurie Savage, who is co-principal investigator for TASC’s administrative core.
-M. Raine
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