By Richard Lee, M.D.
Associate editor, Harvard Heart Letter
When I was a newly minted cardiologist, heart attacks were feared far more than they are today. They terrified people who were having them, and their families, because they were known killers. Heart attacks made doctors nervous, too, since we were less certain about how to treat them and the therapies available to us were less effective than the ones we have at our disposal today.
Make no mistake: myocardial infarction (the technical term for heart attack) is still a life-and-death situation. But it is becoming more and more routine thanks to laboratory and clinical research that has taught us what to do, and how to do it, to save lives.
The numbers tell part of the story. In 1970, nearly 40% of older heart attack victims who made it to the hospital never left, dying there from the attack or its complications. Today, that number is well below 10%. Younger victims fare even better. And instead of lingering in the hospital for a week, some people are now home the next day and back to work within 48 hours (if they want).
What accounts for this remarkable improvement in heart attack survival? Experts have been debating that question in medical journals and at conferences for a decade or more. Here are some of the leading contributors.
Better awareness. Public campaigns since the early 1980s have made people more aware of the signs and symptoms of heart attack and the importance of getting to the hospital as fast as possible. Getting help when a heart attack is just starting can limit its size and severity. In people who arrive at the hospital soon after their symptoms have begun, myocardial infarction can be halted, avoiding measurable damage to heart muscle.
Early angioplasty. Opening a blocked artery with angioplasty and propping it open with a stent returns blood flow to heart muscle. The sooner this is done after symptoms appear, the less damage to heart muscle. Today, the goal is to start angioplasty within an hour of the onset of symptoms. In the early 1990s, only a minority of Americans lived close to a hospital with the equipment and facilities to perform lifesaving cardiac catheterization. Now, because more hospitals have catheterization laboratories, most Americans have rapid access to it — and more heart muscle can be saved by this now-routine procedure.
Advances in drug therapy. The development of streptokinase and other clot-busting drugs was a big step forward in treating heart attacks. The use of aspirin to minimize clot formation was another lifesaving advance. Clinical trials showed that beta blockers and statins protect the heart after a myocardial infarction; wider use of these medications has reduced the number of repeat heart attacks.
Goodbye to bed rest. We used to think that bed rest after a heart attack was essential because it gave the heart time to heal. We now know it is important for heart attack survivors to get out of bed and get moving as soon as possible. This helps prevent blood clots from forming in the legs. These blood clots can cause a potentially deadly pulmonary embolism or stroke.
Evidence-based treatment. In the early 1980s, hospitals tended to have their own particular methods for treating someone who was having a heart attack. These were based largely on opinion and local culture. The growing adoption of evidence-based treatments and systems in clinical medicine takes the guesswork out of treating myocardial infarction and replaces it with methods demonstrated to work. Emergency rooms throughout the U.S. now have checklists in place that streamline heart attack therapy, allowing more people to get the right therapies, and get them faster.
Trends in heart attack survival
Although heart attacks are still feared killers, the percentage of people surviving them has increased steadily since 1970. Today, more than 90% withstand a heart attack.
Dick Cheney's experience
The case of one very high-profile heart attack survivor reflects many of the advances that have been made since the early 1980s. Former Vice President Dick Cheney had his first heart attack in 1978, at age 37. After that wake-up call, Mr. Cheney gave up a three-pack-a-day cigarette habit and worked to correct his sky-high total cholesterol level (over 300 mg/dL). Other heart attacks followed in 1984, 1988, and 2000. Two were treated with angioplasty and stents; one required surgery for a triple bypass. In 2001, Mr. Cheney got an implantable cardioverter-defibrillator to protect against the sudden and lethal heart rhythm known as ventricular tachycardia.
During this period, he was elected to the U.S. House of Representatives five times, served as defense secretary for President George H. W. Bush, was chairman and CEO of the Halliburton Company, and served two terms as vice president. Not bad for someone with such a troublesome ticker.
In a speech he gave at a fund-raiser for Baylor University Medical Center, Mr. Cheney said, "Many of the opportunities I've had would never have come to me at all were it not for steady advances in the practice of cardiology. I might well have faced a much more confined existence, and perhaps even a forced retirement long ago, without the good care I've received from cardiologists." He joked that "for those who wish Dick Cheney had called it quits a long time ago, they can blame it all on [cardiologists]."
After leaving office in 2008, Mr. Cheney had another heart attack in 2010 and, that summer, received a left ventricular assist device just months after the FDA approved these implanted pumps for people with severe heart failure. This pump helps his heart circulate blood. Speaking on NBC's Today show in January 2011, Mr. Cheney talked about living with the device.
In a less dramatic fashion, I see this progress in the patients I care for at Brigham and Women's Hospital. I estimate that up to half of the heart attack survivors I see during an average day would not have survived if they had had their heart attacks 25 years earlier.
These advances in heart attack care are a blessing for the survivors and their families. The effects on the health care system aren't known, since many heart attack survivors eventually develop heart failure, a tricky and costly condition to treat.
We still have a long way to go, of course. There's much yet to be learned about diagnosing and treating myocardial infarction, particularly in the small percentage of people who suffer major damage to heart muscle despite all of our best therapies. We have to ensure that all doctors and hospitals adopt proven, evidence-based strategies. And we need to get the same message out for stroke — that every second counts, so get to the hospital as fast as possible.
But in this chaotic time for medicine and health care, the dramatic improvement in heart attack survival shows the best of what modern medicine can achieve.