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Back from the brink - cardiology services save lives - 01/10/2008

Last September, Charles Frederick’s heart went haywire.
The Berlin resident was at his Thursday morning golf game, and noticed he was a little tired, but didn’t think much of it as he lugged his golf bag uphill to the 16th tee. He took his shot then headed for the 17th green. “As I was walking, I got this terrible pain in the center of my chest — a pain I’d never felt before,” says Frederick, 69. “I started not feeling good, but hit the ball anyway. When I told one of my buddies how I felt, he immediately got me into a cart and to the clubhouse. I remember lying in this cart, with my heart going ‘boom, boom’ and this pain that felt like someone driving a chisel into my chest. I looked down and saw a puddle of sweat in the cart.” Paramedics arrived and gave Frederick four aspirin to chew, some oxygen and a shot of nitroglycerin for the pain. Minutes later, he arrived at The Hospital of Central Connecticut’s New Britain General campus Emergency Department.

ED physician David Mucci, M.D., knew immediately Frederick was having a heart attack (myocardial infarction), and paged cardiologists Milton Sands, M.D. and Alan Kudler, M.D. During a heart attack, the heart’s blood supply is severely reduced or cut off, causing heart muscle to die. But Frederick had a more urgent problem. The blocked blood flow sent his heart into a deadly rhythm called ventricular fibrillation (V-fib). Individual muscle fibers in his heart’s lower, pumping chambers were contracting erratically. “Without treatment, he would have died in minutes,” Kudler says. Mucci and Sands used an electronic defibrillator to shock Frederick’s heart back into a normal rhythm. Paddles placed on the chest deliver an electrical charge designed to force all heart muscle fibers to contract simultaneously. V-fib prevents the heart from pumping blood, so along with the defibrillation, medical residents, pulmonary technicians and emergency department nurses performed CPR to physically push the blood out of Frederick’s heart. “Between the chest pain and the shock from the paddles, it was excruciating,” Frederick recalls. “After the first shock, I told the doctor, ‘Don’t do that again. Just let me go.’ Thesecond time was even worse. After that, I was unconscious.” Frederick was shocked twice more, and the V fib finally stopped.

Time is muscle
Frederick’s heart attack was caused by complete blockage of his left anterior descending (LAD) coronary artery — a condition so deadly it’s nicknamed “the widow-maker.” He was rushed to the hospital’s cardiac catheterization suite, where technicians, nurses and physicians had to defibrillate him three more times before Kudler could perform emergency primary angioplasty. Also called percutaneous coronary intervention (PCI), primary angioplasty involves inserting a catheter fitted with a small, deflated balloon into the groin and threading it to the blocked artery. The balloon is inflated to break up the blockage, then a wire mesh stent inserted to hold the artery open. The American College of Cardiology (ACC) recommends patients receive primary angioplasty
within 90 minutes of hospital arrival. “The sooner you restore blood flow, the less permanent heart muscle damage or scarring occurs,” Kudler says. “That’s why we say ‘time is muscle.’”

The Hospital of Central Connecticut’s New Britain General campus began offering primary angioplasty three years ago. The hospital is one of about 800 nationwide participating in the ACC’s “Door-to-Balloon: An Alliance for Quality”initiative, striving for optimum door-to-balloon times and instituting other quality measures. Primary angioplasty has better long-term effects than treatment with clot-dissolving drugs, says Sands, head of the hospital’s cardiology division. Studies show patients initially treated with primary angioplasty had a 38 percent lower relative risk of dying or having a second heart attack or stroke than those initially treated with medication. “Unfortunately, primary angioplasty isn’t available at all hospitals,” Sands says. Frederick didn’t know this when he told paramedics to bring him to The Hospital of Central Connecticut. But he’s glad he spoke up. “They wanted to take me to a closer hospital,” he says. “I said, ‘No, you take me to New Britain. ’That decision saved my life.” Hours after his angioplasty, he awoke in the hospital’s Critical Care Unit with his wife and other family
members around him. “Dr. Sands came in and said two things to me: ‘A miracle happened here today’ and ‘God doesn’t want you yet,’” Frederick recalls.
“And here I am.”

Seeing with sound waves
Frederick had no prior symptoms of heart disease, and although he has some risk factors — he’s male, over 65, with slightly high cholesterol — he lacks others. He has no family or personal history of heart disease. He’s trim, eats a healthy diet and hasn’t smoked in 43 years. Frederick’s weekly golf games and part-time sales associate position at JoS. A. Bank clothiers in Glastonbury keep him moving. But for patients with a family
history, risk factors and/or heart disease symptoms — chest pain or discomfort, shortness of breath and palpitations — physicians often order testing. Non-invasive echocardiography (heart ultrasound) is most commonly used to diagnose heart failure, valve disorders, artery blockages, arrhythmias, and other conditions. An echocardiographer runs a tranducer that emits and receives high-frequency sound waves over the patient’s chest and images are transmitted to a computer. The advanced imaging equipment at The Hospital of Central Connecticut’s Echocardiography Lab includes color flow Doppler technology that shows blood flow. Nearly 6,000 tests are performed annually at the lab, staffed by two echocardiographers and Medical Director Morgan Werner, M.D. “We can get a clear, three-dimensional image of the working heart with a non-invasive, painless test,” Werner says. Since sound waves can travel poorly through bone, lung tissue and thick chest walls, the hospital also offers transesophageal echocardiograms, in which a special probe is passed through the esophagus and into the chest cavity for a direct “view”of the heart. HCC’s echocardiographers perform tests as outpatient procedures in the Cardiology Department and use a mobile echo unit for bedside tests of hospitalized patients. Werner recalls two recent cases in which the hospital’s “excellent” echocardiography technicians spotted areas of concern requiring a cardiologist’s immediate attention and, ultimately, emergency treatment. “This testing truly can save lives,” he says.

Rehabbing the heart
For Nancy Yalanis’ patients, the prospect of getting on a treadmill can be terrifying. They’ve just had a major cardiac event and most haven’t exercised in decades, if ever. “They look at me and say, ‘You really don’t expect me to do this, do you?’ ”says Yalanis, R.N., of the All Heart cardiac rehabilitation program at the hospital’s Bradley Memorial campus. “They’re very weak when they come here, but after several program sessions, they begin to get their confidence, and their lives, back.” At 35-plus years old, All Heart is the longest-running cardiac rehabilitation program in Connecticut and the second longest-running in New England. Program patients are recovering from major cardiac events and/or have undergone bypass, angioplasty, valve replacements and other procedures. Most begin rehab as inpatients and continue after hospital discharge. The benefits of supervised exercise— just one component of All Heart — can been seen almost immediately, says Robert Malkin, M.D., All Heart medical director. Toning muscle and improving fitness make it easier for the heart to pump blood throughout the body. Pat Watson, 55, started with the New Britain General campus All Heart program in early September, not long after the Aug. 13 heart attack she terms “a wake-up call.” On Oct. 22, she walked her fourth annual half-marathon at the Nike Women’s Marathon in San Francisco to benefit the Leukemia and Lymphoma Society. She turned in her best time yet: 13.1 miles in four hours, 21 seconds. “The cardiac rehab has certainly
helped my endurance,” the Berlin resident says. Watson blames her heart attack
on a family history of cardiac problems along with eating and exercise habits that “could have been better.”

In addition to supervised exercise, she and other All Heart patients receive counseling and ongoing education, learning how to eat better, take their medications, manage symptoms, reduce risk factors (such as smoking and obesity) and deal with stress and depression. The American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology and American Heart Association cite research showing that cardiac rehabilitation programs reduce the risk of death after cardiac illness by 20 to 25 percent — a benefit level similar to that of statin drugs, beta blockers and aspirin.
“Cardiac rehab speeds patients’ recovery and makes them feel better physically and mentally,” Malkin says. “They’re also learning lifestyle habits that can improve their overall health and longevity.” “The program works,” Watson says. “The staff is excellent. They’re kind and encouraging — they know when to push you and when not to.”

These days Charles Frederick is also exercising regularly, watching his sodium intake and taking aspirin, Plavix, a cholesterol-lowering medication and a beta blocker. He doesn’t mind the regimen. He’s happy to be around for his wife, four grown daughters and six grandchildren. “I think about it every day, how close I came to dying,” Frederick
says. “I just can’t say enough about the people at the hospital who pulled me through. I’m just a fortunate person.”