Gettysburg Medical Center
The Clinical View
By P.E. Hoffsten, M.D.
21 February 2007 

WE ARE DOING BETTER

           It was November of 1982.  There had been an early cold snap in the hills and a gentleman had gone there to lay out trails for snowmobilers.  He was higher than his usual elevation here in Pierre and noticed that when he would be riding his snowmobile for an hour or so, he would begin to get chest pain.  He would come back down from the hills and rest and the pain got better.  He had never experienced anything like this and wondered what might be wrong.

          He returned to Pierre to see his private physician and was hospitalized suspected of having angina pectoris.  This is a condition in which the person develops chest pain when parts of their heart do not get enough blood.  When it is unstable, as was occurring in this gentleman, it often is a prelude to a heart attack coming.

          He was hospitalized and had a very unexciting first day.  He was due to have a stress test the next morning, but before that could be done, the heart attack struck.  The artery that was being threatened blocked off completely and a large piece of the front of his heart was dying.  Because of the loss of this muscle in the front of his heart, it was not as strong.  Therefore, it was not pumping as much blood as it had before and he was in great distress.  His blood pressure dropped, his pulse became very rapid, he broke out in a terrible sweat, and he vomited.  He was dying.

          It was 1982 and the use of plaque-melting medicine called streptokinase was being used by the heart doctors in Sioux Falls.  They would infuse the medicine through a catheter that had been passed up to the person’s heart and melt the clot that way.  But in Germany, the ambulance technicians were injecting the clot-melting medicines through the person’s veins in their arm and in this situation it seemed to be working very well.  I called Dr. Paul Carpenter, one of the heart experts in Sioux Falls, and we talked about the possibility of trying to use the medicine intravenously as they did in Germany.  He said that nobody to his knowledge had tried it yet in South Dakota, but in an extreme situation such as this, the medicine might be lifesaving. 

          To that end, fortunately, the hospital had the medicine available for use in other situations.  We used the dose that had been used in the German ambulances.  It was predicted that it would take about thirty minutes to work.  Right on schedule, about thirty minutes after the medicine was injected, he sat up in bed, said that he was feeling much better, his skin dried, he squared up his shoulders, and asked for lunch.  It was like a miracle.  He subsequently was sent to Sioux Falls where a bypass surgery was done to go around the blockages that had caused the clot that we melted.  That was twenty-five years ago and this gentleman is still with us today passing a warm winter in California.

          Heart attacks such as this gentleman had at that time carried about a twenty percent mortality in the hospital.  In the next eight months, I encountered another nineteen heart attacks that were treated with this drug.  Nineteen out of those twenty people survived.  That fall, this experience was summarized and presented to the South Dakota Chapter of the American College of Physicians.  It turned out to be a very good idea and one that has been used frequently over the past twenty-five years.

          The reason for this column is not the use of that medicine at that time.  What is surprising is that in the last year, I haven’t had to use this medicine myself even once.  Even though we have a large number of physicians at St. Mary’s Hospital in Pierre, it has only been used 11 times all year to treat heart attacks there, about half the rate it was in 1982.  Thus, the emphasis of this column is to brag that we are getting better in preventing the heart attacks from ever happening.

          Probably the first and most important step in preventing heart attacks is better blood pressure pills.  Then, we had hydrochlorothiazide and propranolol (Inderal).  Hydrochlorothiazide is still used but propranolol has been supplanted with more effective medications.  In addition, we have three other medications that not only lower blood pressure, but are very effective in preventing heart disease from developing. 

          Secondly, in 1982 there were no meaningful medications to get cholesterol down.  We were still stuck with the bogus idea that diet and exercise would lower cholesterol.  It just doesn’t work for the whole population.  Now, we have medications that are very, very effective in lowering cholesterol.  Today we push to get the bad cholesterol (LDL) down to 70 milligrams percent or less at which point it appears that atherosclerotic build up of cholesterol plaque in our arteries is not occurring.

          Thirdly, in the 1980s we were still having 40% of our adult population smoking cigarettes.  Fortunately that has now dropped down to 26% and with the new cigarette tax, hopefully it will drop further.  The answer to the healthcare provider’s dream is that the state grows broke because the cigarette tax didn’t produce enough money because nobody bought cigarettes.  Wouldn’t that be wonderful?

          The fourth area is one where we are not doing quite so well at and that is dealing with diabetes.  Unfortunately, the weight problem in our society has gotten worse in the past twenty five years and the incidence of diabetes is going up astronomically.  We need to put a great deal effort in this area.

          Nationally, in addition to the experience at St. Mary’s Hospital, the death rate and the heart attack rate in our society is dropping very substantially.  Thank you to all those individuals who care enough to participate in their own health care. The efforts that the healthcare profession, the American Heart Association, and the American Diabetes Association have invested in slowing the damage of this disease is also recognized and appreciated.  We are not done yet, but we are doing better.