Cleveland Clinic Comprehensive Heart Attack Protocol Improves Survival and Reduces Disparities for All Patients, Regardless of Socioeconomic Factors

A new study has shown that a Cleveland Clinic-developed protocol significantly improved the chances of in-hospital survival among patients who experience the most severe type of heart attack (STEMI), and reduced door-to-balloon time, a key factor in the treatment of STEMI, for all patients, regardless of socioeconomic factors.

The protocol, designed to reduce variability in care, may be used as a tool to reduce healthcare disparities during life-threatening, time-sensitive conditions such as STEMI (ST-Segment Elevation Myocardial Infarction). The study’s population included over 1,700 patients across Northeast Ohio, 71% of which were from low-socioeconomic communities.

The study was published today in the Journal of the American Heart Associationand was presented during the Quality of Care and Outcomes Research Scientific Sessions at AHA 2021. This is the first time a healthcare system has shown that a standardized protocol can improve heart attack outcomes overall, for all patients regardless of their zip code.

Heart disease is the leading cause of death in the United States and worldwide, and STEMI, a life-threatening type of heart attack that is caused by a sudden and prolonged blockage of the blood supply to the heart, is a primary cause of death in patients with heart disease.

Nationally, residents of disadvantaged neighborhoods or communities are at increased risk for mental illness, chronic disease, higher mortality, and lower life expectancy. Some population groups living in poverty are more likely to have adverse health outcomes than others. For example, the risk for chronic conditions such as heart disease, diabetes, and obesity is higher among those with the lowest income and education levels.

Studies have shown that the care and outcomes of STEMI patients vary significantly based on a patient’s socioeconomic factors, even after considering differences in cardiovascular risk factors. These disparities in care can lead to increased rates of rehospitalization, diminished quality of life, and higher rates of death after heart attack for patients who reside in low socioeconomic neighborhoods.

“When we first started out on this journey over five years ago, we knew that this was an issue both nationally and locally, and we wanted to see if as a healthcare system we could improve the care of our most vulnerable patients at their most vulnerable time, such as during a heart attack,” said Umesh Khot, M.D., head of Regional Cardiovascular Medicine at Cleveland Clinic, and senior author of the study. “We sought to transform the care of these patients by eliminating care variability so that all patients received the highest level of standardized care every time.”

In 2014, Cleveland Clinic put in place a standardized four-step protocol for STEMI patients designed to minimize variability in care.

The protocol included: (1) standardized emergency department cardiac catheterization lab activation criteria, (2) a safe handoff checklist, (3) immediate transfer to a cardiac catheterization lab, and (4) using the radial artery in the wrist as the first option for access to the heart’s arteries. This approach has been shown to have fewer bleeding complications and improved survival when compared to using the femoral artery.

The study compared outcomes of 1,761 patients from different socioeconomic neighborhoods across Northeast Ohio, before and after the protocol was implemented. One of the major goals of the protocol was to shorten the time it takes to re-open a patient’s blocked heart artery from the time they enter the hospital (door-to-balloon time), and this improved significantly for all patients. In addition, the rate of in-hospital death among patients residing in low socioeconomic neighborhoods decreased by over 50% after the implementation of the protocol.

Samir Kapadia, M.D., chairman of Cardiovascular Medicine at Cleveland Clinic, added, “This study is the first to show how a healthcare organization can transform heart attack care and improve survival in patients no matter what neighborhood they live in. We believe this protocol, which focuses on reducing care variability, can be a model for other organizations working to improve the equity of their care delivery.”