MHI Quarterly


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Publication for physicians that highlights Minneapolis Heart Institute’s clinical expertise and innovative programs

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MHI Quarterly

  1. 1. MHI ™ FALL 2009 A quarterly report from the Minneapolis Heart Institute® Comprehensive Cardiac Emergency Services Volume 5, Number 2 Enhanced by Regional System of Protocol-based Care The Level One Heart Attack Program launched to a country like Denmark, which has a small by the Minneapolis Heart Institute® in 2003 has population and an organized transfer system.” demonstrated that a statewide program using a standardized protocol ensures timely access to According to Barb Unger, RN, director of Cardiac care and improved outcomes among patients with Emergency Services, the success of the Level One ST-elevation myocardial infarction (STEMI). Heart Attack Program is due to collaboration among In ThIs Issue Emergency Medical System (EMS) staff, referring Now, lessons learned in the development of the hospitals, the Emergency Department at Abbott Level One Heart Attack Program have been applied Northwestern Hospital and the Minneapolis Heart PAGE 1 to other cardiac emergencies and adapted to ensure Institute®. Working as partners, they have made Comprehensive Cardiac access to other time-sensitive treatments. accessing services easier, hastened patient transport Emergency Services and streamlined care. At the beginning of this decade, it was clear that Enhanced by Regional System percutaneous coronary intervention (PCI) was “When you need to access a large tertiary center, of Protocol-based Care the preferred treatment for STEMI – but few the first hurdle is figuring out who to call and who hospitals had catheterization labs, and the process does what, while at the same time taking care of the PAGE 4 of transferring patients and initiating treatment was patient. So we created one phone number, one set of Closing the Gender Gap in complicated and inefficient. orders and a standardized protocol,” Unger said. Women’s Heart Health “We felt it was our responsibility to referring To address patient transport barriers, Unger said it PAGE 5 physicians to develop a standard protocol that was was important to make plans that were hospital- Women’s Heart Health Program effective and efficient,” said Tim Henry, MD, who led specific. “Every hospital has its nuances. We needed Current Research the team that developed the Level One Heart Attack to go to the outstate hospitals and understand their Program. “It has succeeded beyond what we ever challenges and strengths.” The Summit: Eliminating imagined – we have cut mortality by 50 percent, and Untimely Deaths of Women the transfer times we have achieved are equivalent A Level One paging system helped to streamline from Heart Disease Continued on Page 2 PAGE 6 Genetic Arrhythmia Center Offers Systematic Approach to Treat Rare Conditions Get Timely Clinical Updates Via Email PAGE 7 Cardiac Device Registry Expanding Its Scope New Physicians at Minneapolis Heart Institute® 612-863-3900
  2. 2. (see MHI™ Quarterly, May 2009). There are Aortic Dissection Program. Because aortic twice as many Emergency Department visits dissection is relatively rare, it may not be an for these conditions as there are for STEMI. immediate consideration for a patient who But while the mortality rate from STEMI presents with chest pain. “But if a patient has decreased, it has remained unchanged for presents with chest pain and it doesn’t quite non-STEMI. add up to MI, you need to be thinking about aortic dissection.” “By reducing practice variations and creating a more efficient way to treat these Important clues include chest pain without patients, we hope to see a similar reduction EKG changes, and sudden, severe chest in mortality for non-STEMI,” said Nicholas or back pain that may radiate to the head, Burke, MD, director of the Chest Pain abdomen and legs. Program. “If we have a patient in Alexandria who has The program has been welcomed by referring atypical chest pain, all it takes is for someone hospitals and physicians because it spells out to think of AD as a possibility,” said Frazier exactly which patients need to be transferred Eales, MD, cardiovascular surgeon at the and which can remain in the community for Minneapolis Heart Institute®. The diagnosis testing and follow-up. can be made with a computed tomography (CT) scan. The AD protocol specifies how While hospitals nation-wide are adopting the CT should be done and includes a process similar treatment protocols for acute coronary to ensure immediate interpretation. If needed, syndrome, the Chest Pain Program is one of CT scans are transmitted to the surgeon in the first multi-hospital initiatives to do so. Minneapolis before the patient arrives. aoRTIc dIssecTIon: When chesT The protocol also establishes blood pressure PaIn doesn’T add uP To MI parameters, specifies which medications to The key to treating aortic dissection is use and streamlines the processes required the ability to quickly distinguish it from to prepare for AD surgery. “Instead of a myocardial infarction (MI). The two longitudinal decision-making process, conditions may present similarly, but the everything is defined by the protocol,” said treatment is quite different. Then it’s a matter Eales. “Having all those steps set up in of getting the patient to the operating room advance so it can proceed automatically is a processes at Abbott Northwestern Hospital. without delay. huge benefit.” “There was nothing new that had to be built or created. It was just streamlining all the The Minneapolis Heart Institute® introduced A study by the Minneapolis Heart Institute steps from the helipad to the cath lab. Once its aortic dissection protocol in 2005. “Our Foundation showed that since implementing our team gets the page, everyone jumps into first priority was education for the Level One the protocol, the mortality rate has decreased action and knows exactly what to do,” said regional network,” said Kevin Harris, MD, by more than 50 percent. Other key quality Unger. cardiologist and director of the Ascending measures are shown in Table 1. This regional, protocol-based approach has been replicated to care for patients with non-STEMI, unstable angina, aortic Table 1 | RegIonal aoRTIc dIssecTIon: Key QualITy MeasuRes dissection, critical limb ischemia and abdominal aortic aneurism and to ensure that, 2003-July 2005 August 2005-present when needed, therapeutic hypothermia for (pre-implementation) (post-implementation) patients suffering cardiac arrest is delivered as Average time to effectively as possible. make AD diagnosis 279 minutes 158 minutes non-sTeMI and unsTable Average time from AD angIna: ReducIng PRacTIce diagnosis to operating room 112 minutes 56 minutes VaRIaTIons Earlier this year, the Minneapolis Heart Percentage of AD cases in which Institute® launched its Chest Pain Program, betablockers were used 46 percent 96 percent which applies protocol-based care to the AD mortality rate 35 percent 16 percent treatment of non-STEMI and unstable angina Source: Strauss CE, Eales F, Hirsch AT, Kroshus TJ, Duval S, Kebede TD, Adolphson GM, Inampudi S, Mitchell, PA, Cohen JD, Unger BT, Orlandi QG, Streckenbach S, Kapsner C, Flavin TF, Kshettry VR, Henry TD, Graham KJ, Harris KM. Improving the process of care for the management of acute aortic dissection. J Am Cardiol Coll 2009;53:A400 2 MHI™ Quarterly
  3. 3. the region. “That’s where it has to begin in Table 2 | abdoMInal aoRTIc aneuRysM suRVIVal order for the therapy to be effective,” he said. October 2005-July 2008 August 2008-August 2009 The Intensive Care service at Abbott (pre-implementation) (post-impementation) Northwestern is also critical to the program. “This treatment involves complex multi- Total number of patients 15 22 system failure in patients with metabolic derangement that goes beyond what most Number of survivors at discharge 11 17 cardiologists treat. That’s one of the unique aspects of our program. Very few places in the Survival rate 73 percent 77 percent state have 24/7 intensivist coverage, which these patients very clearly need,” said Mooney. Source: Minneapolis Heart Institute database® In addition to beginning treatment before patients are transferred, the Cool It abdoMInal aoRTIc aneuRysM: are resuscitated following a cardiac arrest. In Program has not used rigorous exclusions in neW PRoTocol, neW TReaTMenT 2006, Abbott Northwestern Hospital and the determining which patients to treat. “The oPTIon Minneapolis Heart Institute® helped pioneer magnitude of the clinical benefit is so great, Treatment for abdominal aortic aneurysm therapeutic hypothermia in Minnesota and we did not want to withhold treatment (AAA) has been enhanced through the use the treatment has become a standard of care from anyone. As a result, we’ve treated a of a new protocol as well as the development across the state. higher risk group than are included in some of a new treatment option: endovascular previously published studies.” stenting. “We chose to implement the Cool It Program using a state-wide strategy from The results have been remarkable, both in Many aneurysms can be treated with a the very beginning,” said Michael Mooney, terms of the scientific data and individual stent, which is less invasive and has fewer MD, cardiologist and lead on the Cool It patient experiences. “Our survival rates are 70 complications, shorter hospitalizations and a development team. He credits nursing percent when patients have a simultaneous lower mortality rate than open surgical repair. colleagues for helping to bring the program to full cardiac arrest with brain injury. And there a variety of community settings and educating have been spectacular saves – people who Before the protocol was implemented, EMS and Emergency Department staffs across were not expected to survive,” said Mooney. emergency AAA repair using endovascular stents was a process “that on a good day TRacKIng ouTcoMes required dozens of calls in a short time The importance of tracking quality measures period,” said Alex Tretinyak, MD, vascular and patient outcomes and reporting back to surgeon. “Our challenge was to whittle referring hospitals and physicians is another down the process so more of it could happen lesson from the Level One Heart Attack automatically. We worked off the scaffolding Program. “You have to pay attention to the of the Level One Heart Attack Program and details,” said Unger. “You can’t just set up a translated it to do endovascular triple-A system and walk away.” repairs.” The Minneapolis Heart Institute® provides As a result, the time required to diagnose immediate follow-up to physicians and nurses AAA has been reduced by more than 30 from referring hospitals whenever patients minutes, and the time from diagnosis to are transferred. In addition, data collected making the incision in the operating room on cardiac emergency services helps Abbott has been reduced by more than an hour. “If Northwestern and the Minneapolis Heart you can gain an hour in repairing triple-A, Institute® improve services and is made you greatly increase the likelihood that available to regional hospitals for their quality the patient will survive,” said Tretinyak. improvement efforts. The survival rate for AAA patients at the Minneapolis Heart Institute® has increased “It’s clear that if you can standardize care, you since the protocol was implemented, as can improve outcomes. Working with our shown in Table 2. regional system allows us to take this a step further,” said Henry. “Our approach to these cool IT: TReaTMenT begIns problems is to have a comprehensive system. befoRe TRansfeR It’s not just having the best stents or the best One of the most important recent technology. We want to make every part of developments in emergency cardiac care has the care we deliver better for patients.” been the use of therapeutic hypothermia to reduce the risk of brain injury in patients who MHI™ Quarterly 3
  4. 4. Closing the Gender Gap in Women’s Heart Health While women’s heart health has received to educate the public about women and more attention in recent years, American heart disease and to focus more research on Heart Association statistics published in women,” said Grey. Circulation (2009; 119:e21-e181) confirm that disparities remain in recognizing and Through its association with the treating women’s heart disease. Minneapolis Heart Institute Foundation, the Women’s Heart Health Program is At the Minneapolis Heart Institute®, participating in several national studies and cardiologists are closing the gender gap in local protocols that focus on women (see providing emergency cardiovascular care to page 5). women. coMMITMenT To educaTIon “Because of the Level One Heart Attack The Women’s Heart Health Program also Program, the treatment gap has closed. Once sponsors a variety of educational sessions women arrive in an emergency department around the region for women and health they are receiving treatment about as care providers. “We feel that educating quickly as men,” said Elizabeth Grey, MD, people about women’s heart health is one of cardiologist and director of the Women’s the most important services we can provide,” Heart Health Program at the Minneapolis said Grey. This year, seminars focusing on Heart Institute®. women’s heart health have been held in 12 locations throughout Minnesota and Yet, outcomes for women who have had a Wisconsin. heart attack continue to lag behind men’s. “One of the big questions is ‘Why do women A weekly women’s-only cardiac support Elizabeth Grey, MD with myocardial infarction have a higher group is held at the Minneapolis Heart incidence of cardiogenic shock and death Institute® to provide information, for women with heart disease occur in the than men?’” said Grey. “We suspect that encouragement, camaraderie and support to primary care setting. “One thing we and one reason is they may be waiting at home women with heart disease. “As treatment others have noticed is that the typical risk longer before going to the ED, but that’s a advancements have trimmed the hospital profile – the Framingham Risk Score – does hard thing to pin down.” length of stay, there is less time for education not always accurately identify risk levels in and support in the hospital. It also takes women,” she said. “The greatest challenge In addition to providing clinical care time to assimilate information and adopt is deciding who is at risk before an event for women, the Women’s Heart Health new behaviors that will alter coronary risk occurs, and this remains an important Program is dedicated to gaining a better factors,” said Grey. The support group helps issue for primary care physicians as well as understanding of this and other aspects of to address these needs. cardiologists.” women’s heart disease. The Women’s Heart Health Program Also, because women with heart disease Through research, education and clinical at the Minneapolis Heart Institute® in have atypical symptoms more often than care, the program is working to raise conjunction with the Mayo Clinic and the men, they may not notice or bother to report awareness of the risks of heart disease University of Minnesota is also hosting symptoms that may be significant. “People in women, support women and families a summit conference on April 29, 2010: think they are supposed to be feeling pain in creating lifestyles which strengthen Eliminating Untimely Deaths of Women before they worry about their hearts. I ask heart health, nurture and care for women from Heart Disease. The summit is designed about exertional shortness of breath and with heart disease, and add to the body to help chart the next steps in addressing whether there has been a sudden change in of research specific to women and the needs of women with heart disease exercise tolerance. Another symptom might cardiovascular disease. and improving women’s cardiac care (see be chest pressure or heaviness with exertion. sidebar). Often women will say, ‘It’s just an ache that Historically, cardiac research has been I hardly notice.’ But these are indications hindered by the gender gap, leaving women challenges foR PRIMaRy caRe that further tests may be needed,” said Grey. under-represented in many cardiac studies. Grey believes that involving primary care “Often it is what people don’t report or pay But in recent years, “there’s been a huge physicians in finding solutions is critical much attention to that is important in terms push by the American Heart Association because many of the challenges in caring of heart disease.” 4 MHI™ Quarterly
  5. 5. Women’s Heart Health Program Current Research Lite HEARTEN Study (plaque and stenosis) on a risk-adjusted basis Psychosocial stress is a significant risk factor with age and risk-matched controls from for coronary artery disease (CAD). This study both sedentary and fitness activity groups examines the effects of two interventions on who have never been significant runners. the stress responses and vascular functioning Multi-slice CT will be used to characterize the of women with documented heart disease as amount, severity and type of atherosclerotic well as on other subclinical markers of CAD. lesions. The study is currently enrolling Subjects will be randomly assigned to one participants. of three intervention groups: mindfulness- based stress reduction, aerobic exercise or VIRGO Study the control group. The study is currently The Minneapolis Heart Institute Foundation is enrolling patients. (Ruth Lindquist, PhD, a participating center for this Yale University principal investigator). study: Variation In Recovery: Role of Gender on Outcomes in Young AMI Patients. Stress Cardiomyopathy Despite perceptions that young women are Broken heart syndrome, or Tako-tsubo protected from heart disease, it is one of cardiomyopathy, is characterized by acute the leading causes of death in women 55 reversible left ventricular systolic dysfunction years and younger. Building on more than a triggered by an emotionally or physically decade of work studying gender differences stressful event and occurs most frequently in in heart disease, this landmark multi-site post-menopausal women. Scott Sharkey, MD, study will enroll 2,000 young women and has extensive knowledge in this area and has 1,000 men for comparison. As the largest, developed a database designed to study the most comprehensive investigation of young cause and course of stress cardiomyopathy women with heart attacks, VIRGO will identify and to improve the care of patients with this key determinants of recovery and assist in condition. Women account for 97 percent of improving care in this population. (Norma this population. Thiessen, MD, principal investigator) Women’s Marathon Study For more information about these and other This study is a follow-up to the Minneapolis studies or to refer a potential participant, call Heart Institute Foundation Marathon Study the Minneapolis Heart Institute Foundation at conducted by Robert Schwartz, MD. It will 612-863-3833. determine the effects of extreme fitness in women. It will compare female long distance runners for coronary artery status The summit: eliminating untimely deaths of Women from heart disease save the date: april 29, 2010 Marquette Hotel – Windows on Minnesota, Minneapolis, Minn. Join professionals from around the country and honorary guest Mary Pawlenty, first lady of Minnesota, for dialogue and planning to improve women’s heart health and cardiac care. Nanette Wenger, MD, professor of Medicine in the Division of Cardiology at Emory University School of Medicine, will deliver the keynote address. Moderator-led panel discussions will focus on four key areas that are considered critical to improving women’s heart health, including screening and prevention, symptom recognition and delays in seeking treatment, the gender gap in survival and ongoing management. The summit is intended to serve as a call to action for providers, researchers and other stakeholders in the design and delivery of women’s health care. For more information call 612-863-3816. MHI™ Quarterly 5
  6. 6. Genetic Arrhythmia Center Offers Systematic Approach to Treat Rare Conditions syndrome, arrhythmogenic right ventricular aunts, uncles and cousins with multiple last dysplasia, Brugada’s syndrome, left ventricular names who are spread out across the country. noncompaction and catecholamine-induced The structure of the Center allows us to track polymorphic ventricular tachycardia. a great deal of information that otherwise would be unavailable.” These disorders can lead to sudden cardiac arrest and death, but they are often Katsiyiannis noted that the Genetic undetected until a life-threatening event Arrhythmia Center benefits from the clinical occurs. Furthermore, the conditions are so resources available at the Minneapolis rare that the average cardiologist may see only Heart Institute® and Abbott Northwestern a few cases of each disorder throughout his or Hospital. “We have a symbiotic relationship her career – and most cardiologists do not have with many of the other programs,” he the resources to coordinate the extensive testing said. “Because of programs like Cool It, and follow-up that are required when a family is we have people surviving these events affected by a complex genetic disorder. who otherwise might not have survived. Among those survivors are people who we Growing frustration with the lack of guidance have subsequently diagnosed with a genetic in treating such disorders led Katsiyiannis and arrhythmia disorder. This has led to screening his colleagues to seek funding to develop a and follow-up with other family members and systematic approach for screening, diagnosis in some cases, recommending a defibrillator.” and treatment. Katsiyiannis said that the Center is quickly William Katsiyiannis, MD The Genetic Arrhythmia Center is modeled becoming known as a resource when there is after the Minneapolis Heart Institute a sudden, unexplained death due to cardiac A new program at the Minneapolis Heart Foundation’s Hypertrophic Cardiomyopathy arrest. “I think that is a credit to our group Institute® is offering hope for families who (HCM) Center, which was started by Barry of physicians as well as an indication of the have many questions but few answers. It is Maron, MD, an internationally known expert on need. We have family members coming to also giving researchers a unique opportunity HCM. us who have no answers. We’re here to help to study several genetic disorders that are them find some answers and to prevent a not well understood and for which treatment Similar to the HCM Center, the Genetic life-threatening event from occurring in any remains uncertain. Arrhythmia Center will gather information other family members.” about patients and family members and The Genetic Arrhythmia Center, determine over time how best to treat them. led by William Katsiyiannis, MD, an It brings together experts from several areas who are dedicated to improving outcomes, electrophysiologist at the Minneapolis When to consider a Heart Institute®, was created last year with including electrophysiologists, cardiologists, imaging specialists, a genetic counselor and referral to the genetic support from the Minneapolis Heart Institute Foundation and private donors. It serves clinical nurse specialists. “The clinical nurse arrhythmia center: patients and families who are affected by rare specialists are the backbone of the program,” • Family medical history includes genetic conditions like long QT said Katsiyiannis. “It’s not uncommon for them to work with several siblings, children, an unexpected, sudden death before age 40 (including unexplained car accidents or drownings) • Fainting episodes (syncope) Get Timely Clinical Updates Via Email during or immediately after The Minneapolis Heart Institute® is building an email list for those interested physical activity, or as a result in receiving timely clinical information and helpful educational materials for of emotional excitement or patients on topics like Plavix-PPI interaction, a case of the week discussion and the distress. use of fish oil in managing cardiovascular risks. Your address will not be spammed or shared. If you are interested in being added to the Minneapolis Heart Institute® For more information, call the email list, please send a blank e-mail with MHI™ as the subject line to Genetic Arrhythmia Center at 612-775-3905. 6 MHI™ Quarterly
  7. 7. New Physicians at the Cardiac Device Registry Minneapolis Heart Institute® Expanding Its Scope Raed h. abdelhadi,Md, is a cardiac electro- Researchers at the Minneapolis Heart Institute physiologist who joined Foundation are preparing to expand the scope the electrophysiology of a one-of-a-kind independent cardiac device group at the Minneapolis registry. Heart Institute® in August. Abdelhadi completed a The Multicenter Registry was started in 1998 cardiac electrophysiology by Robert Hauser, MD, a cardiologist at the fellowship and cardiovascular Minneapolis Heart Institute®. The Registry medicine fellowship at began collecting failure data on pacemakers and the University of Pittsburgh Medical Center. implantable defibrillators from nine centers. “Our He completed a research fellowship in clinical initial thought was to provide an early warning electrophysiology as well as an internal medicine system on device failure and this has proven to be residency at the Cleveland Clinic Foundation in Robert Hauser, MD exactly what we have done,” said Hauser. Cleveland, Ohio. He earned his medical degree at the University of Jordan in Amman, Jordan. The Registry has been used to track the performance of batteries in pacemakers and defibrillators and to characterize the ways in which the leads connecting the device to the heart can fail. It has also been instrumental in the recall of david s. feldman, Md, Phd, cardiac devices and in a recent legal case involving faulty defibrillators. joined the Minneapolis Heart Institute® in June and is the Currently, 15 centers participate in the Registry. It is unique among device new medical director of registries because participation is voluntary, and it focuses specifically on the Heart Failure, VAD and device failure. The Registry contains information on 7,500 devices, including Cardiac Transplant program. 4,000 pacemakers/pacemaker leads and 3,500 defibrillators. Previously Feldman was the director of the Heart Failure “The value of this registry is that it helps us better manage the care of our and Cardiac program at the patients. We know more about what’s going on with these devices after Ohio State University Medical implantation than anyone else, including the manufacturers and the Food and Center. He received his doctorate of Philosophy and Drug Administration,” said Hauser. Medicine from the Medical College of Georgia. His cardiology fellowship was completed at Barnes- Members of Registry can search the database and information is made available Jewish Hospital, Washington University School of to other researchers by request. In addition, the Registry submits papers and Medicine in St. Louis, Mis. Feldman was an assistant abstracts for publication and presentation at national and international professor of medicine and cardiology at the Medical scientific meetings. University of South Carolina before moving to the Ohio State University. A recent $1 million grant will help to fund further study about the use of cardiac devices and expand the Registry’s scope to include information about all devices implanted at the participating centers, not just the faulty devices. nada b. Memon, Md, “The deficiency in the Registry is that we have the numerator but we don’t is a cardiac electrophysiologist. know the denominator,” said Hauser. “We’ll be able to look at not only device She joined the electro- complications, but clinical complications and that may help us improve physiology group at surgical procedures.” the Minneapolis Heart Institute® in August. Memon For more information, visit or email completed fellowships in electrophysiology and cardiology/electrophysiology at Washington University in PaRTIcIPaTIng cenTeRs St. Louis, Mo., and a cardiology fellowship at the · Minneapolis Heart Institute® · Milton S. Hershey Medical Center University of Texas Southwestern Medical Center. · Montefiore Medical Center · Grey Nuns Hospital She is also board certified in internal medicine, · University of Alabama · Good Samaritan Hospital completing her residency at Washington University. · Mayo Clinic · University Hospital at Stony Brook Memon earned her medical degree at the University · San Pedro Peninsula Hospital · University of British Columbia of Alabama. · Eastern Heart Institute · University of Southern California · Winthrop-University Hospital · Newark Beth Israel Medical Center · Marshfield Clinic MHI™ Quarterly 7
  8. 8. 800 East 28th Street Minneapolis, MN 55407 MHI™ Quarterly is published regularly by the Minneapolis Heart Institute® 09-3528 ®2009 ALLINA HEALTH SYSTEM ® A REGISTERED TRADEMAKR OF ALLINA HEALTH SYSTEM MINNEAPOLIS HEART INSTITUTE® AND MHI™ ARE TRADEMARKS OF MINNEAPOLIS HEART INSTITUTE®, INC. EDITOR IN CHIEF M. Nicholas Burke, MD MANAGING EDITOR/WRITER Mary Pat McGinnis 612-863-3900 CME Events 2009 & 2010 evenings of cardiology in 2009 Thursday, Nov. 5: Northfield, Minn. Thursday, Nov. 19: Crosby & Aitkin, Minn. For information: 612-863-7032 or email emergency cardiac Resuscitation conference Miracle on Ice: Therapeutic hypothermia for cardiac arrest Patients Thursday-Friday, Dec. 3 &4: Marriott Minneapolis Airport For information and to register: The summit: eliminating untimely deaths of Women from heart disease Thursday, April 29: Marquette Hotel – Windows on Minnesota Minneapolis, Minn. For more information: 612-863-3816.