By Tim Bonfield
Enquirer staff writer

The way hospitals treat thousands of heart attack victims throughout Ohio could change in the next three or four years because of a pilot project going on at Mercy Franciscan Hospital Mount Airy and a handful of other hospitals statewide.

But not before stirring intense debate among doctors who disagree over the best way to speed up care for heart attack victims.

Mercy Mount Airy is the first hospital in Ohio to receive a state waiver to perform emergency balloon angioplasty to open clogged arteries for heart attack patients - even though the hospital does not have an open-heart surgery program to provide backup in case something goes wrong.

HEART ATTACK FACTS

• Heart attacks strike 1.2 million people a year. • Heart attacks kill 502,000 people a year. • The average age of a first heart attack is 65.8 for men, 70.4 for women. • The average number of years of life lost due to a heart attack is 11.5 • Within six years of a heart attack, 18 percent of men and 35 percent of women will have another heart attack; 22 percent of men and 46 percent of women will be disabled by heart failure; and 8 percent of men and 11 percent of women will have a stroke. Source: American Heart Association   Open-heart surgery programs Bethesda North Hospital Christ Hospital Deaconess Hospital Good Samaritan Hospital Mercy Hospital Fairfield Jewish Hospital St. Elizabeth Medical Center South University Hospital   Diagnostic-only angiogram services Dearborn County Hospital Mercy Franciscan Hospital Western Hills Mercy Franciscan Hospital Mount Airy* Mercy Hospital Anderson* Middletown Regional Hospital St. Luke Hospital East St. Luke Hospital West *Participating in pilot project to provide emergency angioplasty   Other Ohio hospitals in the waiver program Mercy Anderson (Hamilton County) Southern Ohio Medical Center (Scioto County) Adena Regional Medical Center (Ross County) Community Hospitals of Williams County Eastern Ohio Regional (BelmontCounty) Sources: Ohio Department of Health, Greater Cincinnati Health Council

Heart disease is the No. 1 cause of death in America. Nationwide, about 1.2 million people a year suffer heart attacks and about 42 percent of those people die, according to the American Heart Association. Adding to the toll, many heart attack survivors suffer debilitating heart damage that requires extensive and expensive continuing care.

If the project at Mercy Mount Airy succeeds, it could save some lives. But its biggest impact would be to help more heart attack victims avoid years of disability.

A successful project also could lead to a change in state hospital regulations, which could allow smaller suburban hospitals to compete for patients against big heart centers in the never-ending cardiac services wars.

Beyond the thousands of lives that may be affected, millions of dollars are at stake for competing hospitals and doctors. In Ohio, more than 43,000 people a year get angioplasty treatments to open clogged arteries. Hospital charges for such care range from $20,000 to $30,000 per case.

Since November, 20 heart attack patients have been treated at Mercy Mount Airy, with no deaths reported. Five other Ohio hospitals, including Mercy Hospital Anderson, also have received state waivers, but have not yet treated patients.

"In cardiac care, time is muscle. So the need is to open a blocked artery as soon as possible. We're talking about the difference between 90 minutes and three or four hours," said Dr. Zubair Haq, who leads the program at Mercy Mount Airy.

The biggest risk is that emergency treatment would occur in hospitals that don't have open-heart surgery backup. Hospitals that already perform angioplasty report that potentially fatal complications requiring emergency surgery occur in about 1 percent of cases.

Critics say that allowing community hospitals to do angioplasties could increase that complication rate. But supporters say the potential benefits outweigh the risks.

"The need for surgical backup has become extremely low," says Haq, who has been practicing in Cincinnati for a decade and performs angioplasty at several area hospitals.

He says too many heart attack victims suffer long-term heart damage because, on average, it takes about three hours to transfer a patient from a community hospital to the operating room of a heart center.

A success story

Michael Bootes of Colerain Township was among the first 20 heart attack patients treated by Mercy Mount Airy. The 65-year-old man recalls suffering severe chest pain at about 4:30 p.m. Jan. 19.

When his wife came home at about 6 p.m., he asked her to drive him to the hospital. She called 911 instead.

A life squad with the Colerain Township Fire Department took Bootes to Mercy Mount Airy, where five nurses and three doctors were waiting.

Bootes was treated with balloon angioplasty and a stent and was recovering in intensive care in about 1½ hours.

"My doctor said there was no damage to the heart. It was like nothing happened," said Bootes.

Dr. Zubair Haq (left) says patients like Michael Bootes can benefit from angioplasty done soon after arriving at a hospital, rather than waiting hours for transfer and treatment at a heart center. (Sarah Conard photo)

Transferring him to another hospital would have doubled the time it took to treat him, Haq says, and could have resulted in permanent heart tissue damage.

Haq and other doctors nationwide argue that the technology of angioplasty has evolved to the point that it should no longer be restricted to a few hospitals.

In April 2002, the debate grew when a major study was published in the Journal of the American Medical Association. The study was launched in 1996 after frustrations emerged that it took hours to transfer heart attack patients just a few miles from a community hospital to the prestigious Johns Hopkins Hospital in Baltimore.

The Atlantic Cardiovascular Patient Outcomes Research Trial (C-PORT) went on to study more than 450 patients. It found that patients who got emergency angioplasty in a community hospital were 40 percent less likely to suffer repeat heart attacks or strokes in the first six weeks after treatment than people who received clot-busting drugs while awaiting transfer to a heart center.

At that time, the study's lead author, Dr. Thomas Aversano, said that policies should be changed nationwide to allow more community hospitals to provide angioplasty care.

But in Ohio and many other states, the rules haven't changed. Some doctors say they shouldn't.

Years after the C-PORT trial, the American College of Cardiology still considers angioplasty without open heart backup an unrecommended approach that needs more study.

"The ACC's national guidelines are modeled on data that is very old. But those guidelines are not going to change," says Dr. Sorin Brener, director of the heart attack program at the Cleveland Clinic.

Instead, the college of cardiology supports urging life squads to take heart attack victims straight to fully-equipped heart centers even if another hospital is closer, Brener said.

Better than clot-busters

For several years, the standard of care for heart attack victims coming to hospitals in Ohio that lack open-heart surgery capability has been to treat them with clot-busting medications, then transfer them to a heart center that can perform angioplasty.

Angioplasty involves snaking a catheter through blood vessels to the blocked artery, then inflating a tiny balloon to force open the blockage. Most people also receive a stent to hold the artery open after the balloon is deflated.

Several studies in the past three years have shown that angioplasty is more effective than using clot-busting drugs to restore blood flow to the heart.

"The drugs work about 50 to 60 percent of the time, and not all patients can get clot-busters," Haq said. "On the other hand, about 90 percent of patients are eligible for angioplasty and it is 95 percent successful."

Challenging the rules

Regulations in Ohio and most states require that all angioplasty treatments be done in hospitals that can provide open-heart surgical back-up.

Nationwide, about 15 percent of hospitals are equipped to perform angioplasty at any hour of the day. In Greater Cincinnati, eight of the region's 29 acute-care hospitals have open-heart programs. At least two more have been proposed.

After seeing the data from the C-PORT study, officials with the Ohio Department of Health were convinced enough to allow a pilot project to consider changing the rules.

The Department of Health hopes to gather two to three years of data from several hospitals, said Christine Kenney, health services policy specialist for the department. If the project saves lives and reduces disability, the department would seek changes in state law to allow other community hospitals to provide similar services, she said.

A threat to big centers?

If the pilot project succeeds, every suburban heart attack victim who gets treatment in places like Mercy Mount Airy would be a case lost to central city centers like Christ, Good Samaritan or University hospitals.

"The financial issues are real. This is already a very political process," says Rodney Reider, Mercy Mount Airy's president.

Launching and maintaining an open-heart program can be a huge expense.

Mercy Health Partners has spent about $52 million to launch an open-heart program at Mercy Fairfield, Reider said. But launching the pilot program at Mount Airy cost about $100,000.

The Mercy group has been discussing launching open heart programs at its Mount Airy and Anderson hospitals. But if the pilot project proves successful, launching those services may not be necessary, Reider said.

Beyond emergency care, proving that angioplasties can be done safely without open-heart surgery backup could allow community hospitals to compete in the even bigger market of elective, or non-emergency angioplasty treatment.

Typically, such treatments follow medical tests that detect signs of a partially blocked coronary artery that hasn't become severe enough to cause a heart attack.

Dr. Dean Kereiakes, who recently championed a free-standing, doctor-owned heart hospital targeted for Norwood or Sharonville, still says the community would be better served by a few big heart centers rather than several little ones.

The proposed heart hospital has been indefinitely delayed by a federal moratorium on doctor-owned hospitals. But big centers are better able to concentrate top talent, afford the latest equipment and newest medications, take on complex cases even if they lose money and conduct cutting-edge research, Kereiakes said.

"If transfer times are the problem, then the intelligent thing is for ambulances to not stop (at community hospitals) in the first place," Kereiakes said.

But Haq says, "If we had a system to move patients quickly to the heart centers, I don't have a problem with that. But the reality is, that doesn't happen."

Even if every life squad changed its transport policies, it wouldn't solve the concern. The vast majority of heart attack victims - as many as 70 percent, according to Haq - are driven to the hospital by relatives or by the patients themselves. And by law, hospitals cannot turn away people coming to their emergency departments. So even if a community hospital knows it can't provide the best treatment, it can't help but receive the patients, Haq said.

The Health Alliance of Greater Cincinnati is closely watching the Mount Airy project - for more than one reason.

Alliance officials acknowledge that open heart programs at Christ, Jewish and University hospitals would be affected at least somewhat by suburban hospitals taking on more cases. Yet the Health Alliance also may consider following the Mercy approach at St. Luke West in Northern Kentucky, which currently routes heart attack patients to St. Elizabeth South for treatment.

Some St. Luke staff recently visited Mercy Mount Airy to learn about the program, Reider said.

Unlike Ohio, no special waiver would be needed in Northern Kentucky.

Dr. Russ Vester, director of cardiovascular services for the Health Alliance of Greater Cincinnati and a partner in Cardiovascular & Thoracic Surgeons Inc.,said bigger heart centers would not be deeply hurt by community hospitals providing emergency angioplasty services.

But he opposes the idea of community hospitals doing elective services, which account for most procedures at most heart centers.

"There's a different level of acceptable risk between emergency and elective services," Vester said.

When a person has a heart attack that may kill within hours, a small risk of a deadly complication may be acceptable to speed up treatment. But such a risk is less acceptable if there isn't an emergency. In such cases, getting care at a full-service heart center only makes sense, Vester said.

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E-mail tbonfield@enquirer.com