By Kevin McKeough
On a Saturday night in early March, a 50-year-old man experiencing severe chest pains came to the ER at Rush University Medical Center. The emergency room team quickly determined he was having a heart attack and summoned Quinn Capers IV, MD, the interventional cardiologist on call that evening.
Capers first performed a procedure called a ballon angioplasty. He made a small puncture in an artery in the patient’s wrist and inserted a thin wire and a catheter (a long tube) through it. Guided by real-time X-ray imaging, Capers threaded them through the patient’s circulatory system up to near his heart.
There, Capers inflated a tiny balloon at the end of the catheter to push away the blockage in the patient’s artery that was causing the heart attack. He then deflated the balloon, allowing blood to flow through the artery again. “At that moment, the heart attack was over,” Capers says.
After retracting the catheter, Capers inserted another one through the incision and again navigated the patient’s blood vessels. This time, the catheter carried a small steel mesh tube called a stent. Arriving back in the place where the blockage had developed, Capers placed the stent in the artery to hold it open.
The patient felt so much better once the procedures were finished, he asked if he could go home. After being kept in the hospital for observation for two and a half days, he did.
A dramatic drop in heart attack deaths
Before the procedures Capers performed were available, a severe heart attack patient’s chances for such a successful outcome were much worse. Even with hospital care, “one in three were expected not to make it,” says Weili Zheng, MD, another interventional cardiologist at Rush. Today all but about 1 in 20 of such patients treated promptly in a hospital survive.
These improved outcomes are part of the reason heart attack deaths in the United States have decreased dramatically in the past 55 years. An analysis of public health data by researchers at Stanford Medicine found that deaths from acute heart attack, adjusted for age, decreased by 89% from 1970 to 2022. They published their findings in the Journal of the American Heart Association last June.
Emergency treatments for heart attacks have made great advances during the time period in the Stanford study. Balloon angioplasty first was used to treat a heart condition in 1977 and became widely adopted as a heart attack intervention in the late 1970s and 1980s.
In 1986, a clinical trial demonstrated the effectiveness of medications called thrombolytics that dissolve blood clots, leading them to become standard care for heart attacks and strokes. Also in 1986, a coronary stent was used along with angioplasty for the first time, a combination that now is standard practice.
Gary Schaer, MD, a longtime interventional cardiologist at Rush, notes that these treatments, and his specialty itself, didn’t even exist when he began medical school in the mid-1970s. “There were no balloons. There were no stents. There were no ways for doctors — interventional cardiologists like me — to open up and unclog blocked coronary arteries,” he reflects.
“All of this technology, all of these tremendous advances have established themselves during the time that I’ve been in practice.”
Thank you for not smoking
Also contributing to this welcome decline, preventive medicine and healthier lifestyles have led to far fewer heart attacks occurring in the first place. More than 800,000 people in the U.S. still have a heart attack each year, according to the federal Centers for Disease Control and Prevention. However, “the incidence of the largest type has been cut approximately in half,” Capers says.
(That 50% decrease is for heart attacks caused by an artery to the heart being blocked completely. The rates for heart attacks caused by a partial blockage have stayed the same, likely because better diagnostic methods are detecting more cases.)
A big part of heart attack prevention is the decrease in cigarette smoking, a major risk factor for heart attack. The chemicals in cigarette smoke damage the heart and blood vessels, which increases the likelihood of a blockage developing in the arteries.
According to the CDC, 14% of the U.S. population smoked in 2019, compared to 40% in 1970. “I’m old enough to remember cigarette smoking was everywhere,” including restaurants and on airplanes, Capers recalls.
A tremendous advantage from statins
Healthier diets and physical activity also have played a role. Eating right and exercising can reduce the accumulation of cholesterol in the walls of the arteries, preventing it from building up to the point that it causes a heart attack.
For people with high cholesterol, medications called statins can halt its accumulation in the arteries, and even reduce that accumulation. Statins are a relatively new drug — the U.S. Food and Drug Administration first gave a statin approval in 1987. Now in wide use, they’ve greatly reduced the risk of heart attack.
“We’ve found tremendous advantage to patients being on these medicines,” Capers says. “Our message has been to get your LDL (bad) cholesterol as low as possible, and you’ll get your risk as low as possible,” Zheng adds.
Know the warning signs
Sometimes statins and other cholesterol-lowering medications aren’t enough, or people may want another option. Interventional cardiologists like Capers, Zheng, and their colleagues at Rush can perform procedures to reduce the chances of a heart attack.
Capers recommends people first consult their primary care provider if they have four or more of the main risk factors for heart attack: smoking, high cholesterol, high blood pressure, diabetes, a sedentary lifestyle, and a family history of heart attacks.
They especially should be concerned if they experience pain, tightness or squeezing in the chest that lasts for several minutes or more.
Zheng observes that pain “radiating to the jaw or both shoulders (also) is classic cardiac chest pain.” In women the pain tends to occur in the neck, and heart attacks in women often have other atypical symptoms, such as fatigue and nausea.
Those symptoms are particularly serious if they occur along with physical exertion like climbing steps, or with shortness of breath. “That’s a dangerous sign threatening that you might be at risk for a heart attack,” Capers warns.
A stent in time saves lives
The Rush interventional cardiology team can diagnose people at potential heart attack risk using noninvasive testing. “No needles, no punctures,” Capers assures.
If their imaging shows a severe blockage in a patient’s artery, the team can clear it either by performing a balloon angioplasty, inserting a stent, or most often doing both. It’s the same pair of procedures Capers performed for the patient that came to the Rush ER, but done proactively, without the life-and-death drama.
The Rush team inserts between 600 and 650 stents a year. “Most stents are implanted in people with blocked arteries who are having chest discomfort, but they have not had a heart attack,” Capers explains. “In most of these cases, the artery is narrowed but not completely blocked. The narrowing reduces blood flow to the heart muscle.”
Chipping away at a hard problem
Along with cholesterol, calcium also can build up in the arteries and cause blockages. “It’s disease that’s very severe that’s developed over time,” Zheng says.
A CT scan can determine the level of calcium in the artery. If the level is dangerous, members of the interventional cardiology team are experienced in a procedure to remove or modify the calcium.
Known as a complex higher-risk and indicated patients (CHIP) procedure, the name reflects the difficulty of treating the condition. “Calcium is really, really hard to remove and stent,” Zheng says.
Prior to using a balloon device, the doctors use ultrasound waves or a miniature drill to break up the calcium into tiny particles. “We chip, chip, chip the calcium until it’s removed or softened and we can expand the balloon,” Zheng explains.
Like the balloon, the drill and ultrasound device are attached to a catheter that is passed through a small incision and traverses the bloodstream. “It’s as if they’re on a monorail,” Zheng says.
“We do this routinely. Rush has expertise in dealing with these very stubborn cases of coronary artery disease.”
Lives saved in just an hour
Despite the advances in preventive medicine, about 100 patients will seek emergency care for a heart attack from Rush each year. Similar numbers will arrive at the ERs of other Chicago-area hospitals.
When they get there, quick treatment is essential. Without oxygen in the blood reaching the heart, it begins to die within minutes. That urgency is why doctors say “time is muscle.”
The patients with the best chances of a good outcome are those that reach a hospital within an hour of having chest discomfort, Capers says. The national quality standard for providing treatment for a heart attack is 90 minutes after a patient arrives.
The ability to intervene so quickly with a good chance of success inspires both Zheng and Capers. “For us interventional cardiologists, it’s the most gratifying thing we do, because the patients come in and literally the pain is indescribable,” Capers says. An hour later, after he’s treated them, “just like that, the pain goes away.”
The ability to make such a decisive impact is a main reason Zheng decided to become an interventional cardiologist. “It’s certainly one of the most satisfying fields,” he says. “When someone is having a heart attack, you can go in knowing you not only can treat them but reverse something that could be fatal.”
