Medical research has revealed enough about the causes and prevention of heart attacks that they could be nearly eliminated. Yet nearly 16 million Americans are living with coronary heart disease, and nearly half a million die from it each year.
It's not that prevention does not work. In fact, age-adjusted death rates for heart disease dropped precipitously in the past few decades, said Dr. Elizabeth Nabel, director of the National Heart, Lung and Blood Institute at the National Institutes of Health. But the concern, Nabel and others say, is that much more could be done.
In many ways, scientists' hard-won and increasingly detailed understanding of what causes heart disease and what to do for it often goes unknown or ignored. The result, researchers say, is a huge disconnect between what is possible and what is actually happening.
The urgency of getting help immediately - doctors call it the golden hour - has been one of the most difficult messages to get across, in part because people often deny or fail to appreciate the symptoms of a heart attack.
Most patients describe symptoms as discomfort in the chest that might, or might not, radiate into the arms or neck, the back, the jaw or the stomach. Many also have nausea or shortness of breath. Or they break out in a cold sweat, or have a feeling of anxiety or impending doom, or have blue lips or hands or feet, or feel a sudden exhaustion.
But symptoms are often less distinctive in elderly patients, especially women. Their only sign might be a sudden feeling of exhaustion just walking across a room. Some say they break out in a sweat. Afterward, they might recall a feeling of pressure in their chest or pain radiating from their chest, but at the time, they say, they paid little attention.
Patients with diabetes might have no obvious symptoms other than sudden, extreme fatigue.
"I say to patients, 'Be alert to the possibility that you may be short of breath,'" said Dr. Elliott M. Antman, director of the coronary care unit at Brigham and Women's Hospital.
Other times, said Dr. George Sopko, a cardiologist at the National Heart, Lung and Blood Institute, symptoms such as pressure in the chest come and go. That is because a blood clot blocking an artery is breaking up a bit, reforming, breaking and reforming.
But most people - often hoping it is not a heart attack, wondering if their symptoms will fade, not wanting to be alarmist - hesitate far too long before calling for help. At least half of all patients never call an ambulance.
"The single biggest delay is from the onset of symptoms and calling 911," said Dr. Bernard J. Gersh, a cardiologist at the Mayo Clinic. "The average time is 111 minutes."
There also is the question of how, or even whether, the patient gets either of two types of treatment to open the blocked arteries. known as reperfusion therapy. One is to open arteries with a clot-dissolving drug such as tPA, for tissue plasminogen activator.
"These have been breakthrough therapies," said Dr. Joseph P. Ornato, a cardiologist and emergency medicine specialist who is medical director for Richmond, Va. But "even the best of the clot buster drugs typically only open up 60 to 70 percent of blocked arteries - nowhere close to 100 percent."
The drugs also make patients vulnerable to bleeding, Ornato said. One in 200 patients bleeds into the brain, having a stroke.
The other way is with angioplasty. Cardiologists say it is the preferred method under ideal circumstances.
During a heart attack or in the early hours afterward, stents are the best way to open arteries and prevent damage. That, though, requires a cardiac catheterization laboratory, practiced doctors and staff on call 24 hours a day. The result is that few get this treatment.
"We can open 95 to 96 percent of arteries, and bleeding in the brain is virtually unheard of. It's a safer route if it is done by very experienced people and if it is done promptly. Those are big ifs," Ornato said.
Most hospitals cannot offer angioplasty because they do not have enough patients for a team of doctors to maintain their skills.
Antman suggests that heart disease patients ask their doctor if there is a hospital nearby that does angioplasty around the clock. If so, they might want to discuss with their doctor whether to ask that an ambulance take them there if they are having a heart attack.
Opening an artery is only the start of treatment. The next part is at least as problematic: Patients have to get the right drugs, in the right doses, and have to take them for the rest of their lives.
"Care is getting a lot better," Peterson said. "But the only caveat is that they are only really looking at 'Did you get therapy?' No one is looking too closely at 'Did you do it right?'"
For example, he said, a recent study found that heart attack patients were getting blood-thinning prescription drugs to prevent clots, as they should, but up to 40 percent were getting the wrong dose, usually one too high. And even if every prescription were exactly right, as many as half of all patients stop taking many or all of their drugs.
Antman has a message for patients: With a disease as serious as heart disease, those who take responsibility are often the ones who survive.
An ounce of prevention
Heart attacks can be virtually prevented if people avoid smoking and control cholesterol, blood pressure and blood sugar, says Dr. Daniel Levy, director of the Framingham Heart Study. He explains:
Suppose a 50-year-old man doesn't have diabetes, doesn't smoke and keeps his cholesterol and blood pressure in nationally recommended ranges. Over 45 years, his chance of having a heart attack or symptoms of heart disease is 5 percent. A 50-year-old woman with those risk factors under control has an 8 percent chance, slightly higher because women live longer. But only 5 percent of 50-year-olds have those risk factors under control.