CCC 2013: Fine-Tuning Heart Attack Care

October 1, 2013

For patients experiencing an ST-elevation myocardial infarction (STEMI), the most dangerous type of heart attack, treatment in a dedicated regional program saves lives. However the benefit specifically to elderly STEMI patients—aged 75 or older—from rapid treatment has not been clear. Among several presentations by the Heart Institute STEMI team led by Dr. Michel Le May, MD, researchers showed that shorter door-to-balloon times reduced the probability of death within 30 days after treatment in elderly as well as younger patients. This advantage held despite the fact that elderly patients were more likely to die during the initial hospitalization, and also had higher rates of cardiogenic shock, stroke, and major bleeding.

Another study looked at early results from the Heart Institute’s therapeutic hypothermia (TH)—rapid cooling—program for heart attack patients who remain comatose after resuscitation. These patients are at very high risk of brain damage or death. Out of 154 patients treated with TH consecutively at the Heart Institute, 66 per cent survived hospitalization and 57 per cent had a good neurological outcome. “A regional [cooling] program is feasible and appears to be associated with survival and favorable neurological outcomes comparable to results from randomized trials,” stated the researchers.

New medications raise new questions for STEMI patients. Heart Institute investigators examined the use of bivalirudin, a new anticoagulant, in STEMI patients who required TH, compared with a heparin-based anticoagulation regimen. Use of bivalirudin alone resulted in slightly fewer in-hospital deaths, stokes, major bleeding, and additional heart attacks, and slightly reduced mortality, indicating that it is safe and effective in these patients.

Another study looked at the safety of adding warfarin to anti-clotting therapy for STEMI patients who have an unclear clinical indication for such an addition. The researchers found that, for patients with apical akinesis or dyskinesis—two type of damage to heart muscle—adding warfarin increased the incidence of stroke, bleeding, and total adverse events up to six months after treatment. They recommended changing clinical guidelines to discourage warfarin use in these patients.