Taking Heart: New Hanover County’s Cardiology Program

Poets politicians artists and comedians alike have extolled the virtues of the human heart lamented its foibles and prized its strength. The heart is as much a metaphor for courage love and faith as it is the muscle responsible for pumping 1 900 gallons of blood throughout our bodies each day. While poets and pundits still romanticize this most essential of organs scientists and physicians have learned a great deal about the inner workings of the real thing.

HEART CARE HISTORY

The field of cardiology has come a long way since 1628 when an English doctor named William Harvey first described the way that blood circulates throughout the body.

In 1903 Willem Eintoven a Dutch physiologist developed the echocardiograph the forerunner of today’s EKG. Then in 1938 American surgeon Robert Gross performed the first heart surgery. Thirteen years later in 1951 U.S. surgeon Charles Hufnagel developed a plastic valve to repair a faulty valve in the aorta. The very next year surgeon F. John Lewis another American performed the first successful open-heart surgery. In 1961 American cardiologist J.R. Jude was in charge of the first external cardiac massage to restart a heart and six years later South African surgeon Christiaan Barnard performed the first complete heart transplant. 1977 marked the first coronary angioplasty performed in Switzerland to open up a patient’s blocked coronary artery. Less than a decade later a pair of French doctors inserted the first stent — tiny metal tubes that prop the artery open after balloon angioplasty in order to prevent arterial collapse. Then in 2003 the FDA approved the first drug-eluting stent — metal stents coated with a substance that affects the artery’s ability to re-narrow.

Today advances in cardiology include 64-slice CT machines four-dimensional ultrasounds techniques to cool the body down and limit organ damage cardiac MRIs and beating-heart surgery — all of which are accessible right here in New Hanover County.

This was not always the case says Dr. William Holt a cardiologist with Hanover Medical Specialists who has practiced in the area for the past 25 years. “When I first came to Wilmington if you came in with a heart attack our job was to get you out of Wilmington as fast as possible ” he admits. Back then there was a Cardiac Care Unit (CCU) at the hospital with eight beds but it wasn’t equipped to handle serious emergencies. For transportation to Duke or Chapel Hill in these urgent cases the hospital used the Ft. Bragg Army helicopter. There was just one problem: In cardiac emergencies time is of the essence and there was no telling when the helicopter would arrive — if at all.

“The military had to authorize a mission ” Holt says wincing. “If everything went well the trip could be accomplished in two to four hours. If it didn’t go well it could take all day or wouldn’t happen.”

The situation improved a bit when Duke got their Life Flight helicopter and offered that as a service. “It was a small step in the right direction but there was only one helicopter and they were very busy. On a good day it could take two hours ” Holt says. New Hanover County physicians were still losing valuable time in treating cardiac care patients — time that could mean the difference between life and death. Meanwhile an increasing number of individuals were moving to the Cape Fear area increasing the pool of potential patients. Add to that the fact that the density of coronary disease in southeastern North Carolina is one of the highest in the country and the way forward was clear: By 1985 Holt says New Hanover County was sending more than 600 patients per year to Duke Wake Forest Charlotte and Chapel Hill numbers that could support a local cardiac program and the medical community concluded that the time had come to take a serious look at improving the scope of what New Hanover Regional Medical Center (NHRMC) had to offer.

DIAGNOSTIC CARDIOLOGY

The next two years were spent organizing the program and getting it off the ground says Holt. One of the first programs to be put in place was cardiac rehabilitation. Until a permanent location could be found the program was based at the Wilmington Athletic Club. “They let us use the gymnasium for one hour three days a week ” Holt says.

In 1986 the NHRMC CCU went from eight beds to 16. Then on July 27 1987 they did their first diagnostic in what is now Room 1 of the (cardiac catheterization) lab.

In 1988 the hospital hosted its first bypass operation — which was performed on one of Holt’s patients. Then in December of 1988 the first angioplasty was performed at NHRMC. Today the hospital boasts the area’s only open-heart surgery program and in 2006 NHRMC’s Heart Center was named a Cardiac Center of Excellence by Blue Cross Blue Shield North Carolina. The hospital is at the forefront of many technological advances in diagnostic and interventional cardiology. Still Holt cautions that it’s important to weigh your options carefully before jumping on the technological bandwagon.

Dr. Greg Roberts a general cardiologist who has been with Wilmington Health Associates for the past year and a half could not agree more. Though Roberts may be relatively new to the field of diagnostic cardiology the creed by which he treats patients has been around for centuries. Sitting in his office surrounded by cardiology tomes journals and stacks of paper Roberts quotes the noted late physician William Osler: “Be neither the first nor the last to use new technology.” And Roberts adds be aware of the potential risks and benefits of any procedure.

“We’ve got a specialty CT scanner now that’s 64-slice — it’s got 64 detectors ” Roberts says. “We slow a patient’s heart rate to 40-50 beats per minute; it just takes two seconds to take a picture.” Many physicians thought that this scanner would prove to be an excellent screening device for potential cardiac problems — and in the right cases it can be. However Roberts says the radiation is a lot higher than that of a traditional CT scan and studies have shown that patients who undergo this procedure have a higher risk of developing certain kinds of cancer. “The numbers are about 1 in 200 of someone developing a cancer they wouldn’t have had otherwise ” he says. “That’s not an insignificant risk.”

Soon NHRMC will have another piece of new technology: the four-dimensional cardiac ultrasound. “It has a real-time transducer; you can get multiple images and then do post-manipulation of that data ” Roberts says. With the 4-D ultrasound physicians can examine images of the heart on the computer and regard them from different angles an approach that can prove helpful prior to surgery. Plus Roberts says with ultrasound there’s no radiation involved.

And for more than a year the hospital has had a cardiac MRI (magnetic resonance imaging) machine that allows doctors to view the heart in a way that’s similar to the echocardiogram.

The 64-slice CT scanner 4-D ultrasound and MRI are all diagnostic tools essential in determining what’s going on inside the heart and surrounding arteries. Once physicians have figured out what’s wrong the next step is determining a course of treatment — and that’s where interventional cardiology comes in.

INTERVENTIONAL CARDIOLOGY

There are of course the old standbys — angioplasty and stent. “It’s really cool to be able to do something that fast ” Holt says. “One day you can’t walk up the stairs without getting out of breath and the next day you’re playing 18 holes of golf.” And then there’s bypass surgery a tried-and-true procedure that nonetheless requires a substantial recovery period — something that doctors at NHRMC are changing via a technique called beating-heart surgery.

Typically during bypass surgery a patient’s heart is stopped in order for surgeons to be able to work on it. Blood is circulated by a cardiopulmonary bypass or heart-lung machine. “You’re talking about a thread that’s one third the width of a human hair arteries that are an eighth of an inch across; if you let go of the thread it would float ” Holt says. Operating on this scale is challenging enough; if the organ in question was in motion surgery would be impossible. Now surgeons at NHRMC utilize a device that fits around the part of the heart where they’re operating holding that part still. The bypass machine — and stopped heart — are no longer necessary.

For patients who collapse outside the hospital but survive NHRMC utilizes an approach called Arctic Sun a noninvasive way to lower the body’s temperature. “It cools the body down so you don’t need as much oxygen when you’re getting the treatment started — it prevents some brain damage and body tissue injury ” Holt says.

In 2007 the hospital also implemented Code STEMI an alert system that notifies the cardiologist on call cardiac interventionist and emergency room doctor that there’s a patient with a heart attack in progress. The hospital’s original goal was to treat Code STEMI patients in under 90 minutes; now they have reduced the treatment time even further something to which patient Pamela Federline can attest. “I had the worst kind of heart attack you can have ” she says. “They call it the Widowmaker.”

PATIENT’S POINT OF VIEW

Fortunately Federline was already in the hospital when the heart attack took place; shortness of breath and mild chest pain had motivated her to come in the night before and the presence of an elevated cardiac enzyme motivated the staff to keep her for observation. “At five minutes to five the next morning I felt like my chest was going to explode. It was very painful — I could not breathe ” Federline says. Desperate she pressed the call button for help.

“They were in my room in under a minute with an oxygen mask and a morphine drip. It’s amazing how fast it happened. In 15-20 minutes they’d run an EKG strip and then I went into the cath lab ” Federline says. A single mother she had just enough time to call Nick her 18-year-old autistic son who had begged her to go to the hospital the night before. “I was awake during the procedure. I remember looking up while they were in my heart seeing the wire go in and thinking ‘Wow that’s my heart ’” she says in wonder.

Now back to work Federline credits NHRMC’s Code STEMI procedure with saving her life. “There were real positives all the way around ” she says.

PREVENTION IS THE GOLD STANDARD

For all of the incredible diagnostic and interventionist advances what cardiologists like Roberts and Holt would like most is to render these approaches unnecessary — at least in the vast majority of cases. In cardiac medicine prevention is the gold standard.

“It’s the Holy Grail of cardiology — why does plaque form?” Holt says. Scientists debate whether plaque formation is due to infection an environmental toxin genetics or some combination of the three. One day perhaps there will be an immunization against plaque formation or even gene therapy. The real danger Roberts and Holt say is from “vulnerable plaque ” which can cause inflammation infection and artery blockage. Currently Holt says there’s the C Reactive Protein (CRP) blood test which analyzes blood for the presence of proteins that indicate inflammation. Though controversial in some quarters CRP is thought to be an excellent predictor of future heart attack or stroke.

Roberts also emphasizes the importance of preventative care which he recommends to healthy individuals who wish to stay that way as well as to cardiac care patients in recovery. The basic tenets will come as no surprise: Not smoking diet and exercise paying attention to your blood pressure cholesterol and blood sugar levels and if your doctor recommends it taking one aspirin per day. There are always exceptions Roberts says but for most individuals the basic rules of prevention will make a big difference.

As a physician Roberts’ priority is working one-on-one to ensure that his patients are receiving the best care possible. Though his field is not public health or screening he is well aware that many individuals do not have access to the preventative or ongoing cardiac care they need — despite the fact that excellent facilities exist in this community. “As a country we need to look at our priorities and values ” he says. “There is a huge dichotomy in America between rich and poor. As a human-rights-valuing society let’s make sure that our people are cared for.”

An admirable sentiment… and an ambition not for the faint of heart.