The medical term “door-to-balloon time” refers to the time a heart attack patient comes through the doors of the hospital to the time an angioplasty is performed to clear the blockage causing the attack. The American College of Cardiology and the American Heart Association have established a 90-minute door-to-balloon time as the quality of care benchmark.
According to the U.S. Department of Health and Human Services’ Web site, hospitalcompare.hhs.gov, top hospitals meet the 90-minute standard 88 percent of the time. The average for all reporting hospitals in the U.S. is 58 percent and in Massachusetts, 67 percent.
Locally, Boston Medical Center meets the standard 81 percent of the time, Massachusetts General Hospital 59 percent and Lahey Clinic in Burlington 41 percent.
Gale said Melrose-Wakefield Hospital averages an 82-minute door-to-balloon time.
“The feeling is that a lot of patients are going into Boston,” she said. “If you’re having a heart attack, where should you go? Do you drive 30 minutes into Boston through traffic, or do you have a setting within the community where you can get treatment right away?”
Dr. Carl Turissini, director of interventional cardiology at the center, said door-to-balloon time is the basis for the entire program. He said several different aspects factor into a successful angioplasty program, and they all involve speed — the time until a patient has an EKG performed by a triage nurse to the time the patient is seen by an emergency room doctor to the time when the on-call team is paged to get the emergency doctor and staff into the room.
“In a lot of hospitals there’s a lot of links in the system where things can fall through the cracks and take extra time,” Turissini said. “That’s one of the reasons why so many hospitals have a hard time getting their door-to-balloon time under two hours — most of our staff live locally, most of the doctors that do this are within a 15-minute drive of the hospital.”
He added that the doctors working in the center have been working in downtown Boston hospitals for most of their careers, in addition to their work in the Hallmark Health system. Turissini himself works a day and a half a week at Mass. General.
“The people that do this, we’re all very experienced, high volume operators. I’ve done probably close to 5,000 catheterizations [any procedure using a catheter threaded to the heart, such as angioplasties] — and I’m not that old,” he said.
Minimally invasive, quick to action
Once patients are in the “cath lab” and on the table, doctors can perform minimally invasive procedures such as balloon angioplasties and stenting to clear up blockages quickly with the least amount of damage to a patient’s heart and body. Turissini said the actual procedures used to stop a heart attack take only 15 to 20 minutes and most the door-to-balloon time is lost on waiting in emergency rooms and getting the staff in.
As an example, Turissini showed a heart attack recorded by the center’s state-of-the-art imaging center. The 70-year-old patient had arrived at the hospital two weeks ago complaining of chest pains.
Once a heart attack was diagnosed in the emergency room, Turissini was called in and they inserted tubes to take pictures of the patient’s arteries, pinpointing an area where one artery narrowed to almost completely closed, followed by a large clot behind the blockage.
Turissini performed a balloon angioplasty to open the artery, used a catheter to suck out the clot, inserted a stent tube to keep the artery open, and presto — the patient’s heart attack was aborted.
Dr. Neil Denbow, an interventional radiologist at the center, used imaging to show how another patient had two aneurysms — localized, blood-filled bulges in a blood vessel caused by disease or weakening of the vessel wall — in the pelvis and leg.
To alleviate the first aneurysm, Denbow inserted small tubes that used coils to slow blood flow and reduced the size of the aneurysm, which decreased the chance that it might burst. Then, the second aneurysm was treated with a stent graph.
“Sometimes people will make a small incision to gain better access,” he said. “But nonetheless, compared to what would [typically] need to be done for this — it’s much more involved surgery, much more aggressive and for an elderly person who might not be able to tolerate it, it really changes things. The important thing is it’s durable and effective treatment for something that previously required a lot more invasive surgery.”
“On the way to expose the site they’re doing a lot of dissection, which is subsequently trauma to the patient,” he said. “What we’re doing is like plumbing. Your plumber goes into your sink, snakes a pipe down, snakes a tube down, that’s what we’re doing. We get into the tube and then we start snaking wires around.”
For more information on the Hallmark Health Cardiac & Endovascular Center at Melrose- Wakefield Hospital, call 781-979-3999 or visit hallmarkhealth.org/cardiacendovascular.php.
Collaboration at Cardiac and Endovascular leads to preventative measures
In addition to emergency response to heart problems, Melrose-Wakefield Hospital is currently one of seven community hospitals in the state performing elective angioplasties — without cardiac surgery — onsite as part of a state Department of Public Health project to determine if the procedure is safe and provides quality patient care, said Elaine Gale, Hallmark Health’s system director of cardiac and endovascular service.
Dr. Carl Turissini, director of interventional cardiology at the center, said patients complaining of chest pain or registering abnormal stress tests can take advantage of elective angioplasty, if deemed necessary, to stave off a possible heart attack or problems down the line. Gale said the hospital has vascular screenings twice a year and has a free heart screening. Dr. Neil Denbow, an interventional radiologist at the center, said discoveries of aneurysms are usually incidental findings, making screenings important.
“We realize that the baby boomers are there ... vascular disease and heart disease is number one, so we have people out there that don’t even know they could have a time bomb,” she said. Turissini added that because vascular problems are so closely related to heart problems, “it’s a whole body disease,” hence the collaboration within the center.
“Patients who have a blockage in the heart often have blockages elsewhere,” he said. “If you have a blockage in your leg, your biggest [risk] of dying in the next five years is [due to] your heart. The legs don’t kill you — you can lose a leg and get it amputated — it’s the heart that kills you. That type of person needs to be on cholesterol drugs and screened by cardiologists and by doctors to make sure they don’t have any heart problems.”
The new state-of-the-art imaging center, where doctors can look at various images and reports for a patient all on one screen also help prevent future problems and fix current ones, Denbow said.
“Before this, you’d go and look in the file room, and you’d speak to someone and the film would be lost and someone would take the film to the operating room,” he said. “When you’re looking at something to compare to look at study A and study B and ask, ‘Has there been change,’ if you can’t find study B — that was a problem throughout radiology in every hospital in the country. With this, it changes everything.
For example, if you want to send a study to another hospital and get a second opinion from a physician, you burn a CD and send it, just like you would a file.”
In addition to decreasing the time a patient spends in recovery, the minimally invasive procedures also increase mobility and decrease the risk of other illness setting in, such as pneumonia, strokes or infections, Denbow said. He compared surgery to sewing and how, like a tailor, surgeons first need to access the site where they will be sewing.