Door to needle time

The New Straits Times today carried an article on Kuala Lumpur Hospital's current strategy in the management of acute heart attacks. A casual glance makes one rather proud that the system has gained some award, albeit the Director-General of Health trophy. Humble as it is, it is still an achievement to win the National Quality Award 2005.

On closer examination however, I failed to see the "door to needle" time given to us. The door to needle time describes the time taken to administer the clot buster medication, eg IV streptokinase, or IV rTPA, after the patient has entered ER door. It is a test of the system's ability to respond to a heart attack emergency. The shorter the door to needle time, the more efficient the ER is to cope with a heart attack emergency.

We are all working towards a door to needle time of 20-30 mins. In an average first world country, the door to needle time is an average of 60mins. That is deemed too long and has resulted in certain countries training ambulance units and even firemen to fax an ECG from the home of the patient to the nearest hospital, following a 999 call, and upon confirmation by the cardiologist at the hospital, administer the clot-buster medication either at the home or in the ambulance on the way to hospital.

Obviously this is a serious attempt to shorten the door to needle time, because the sooner the patient suffering a heart attack receive the clot-buster, the sooner the artery blood clot go away, the sooner blood flow down the heart atery, the sooner the heart muscle recover. The has given rise to the term, "TIME IS HEART MUSCLE RECOVERY ".

Perhaps, the reason why Dr Jeyaindran, the critical care medicine specialist in KLH did not know the door to needle time was because he did not give his heart attack patients the life-saving IV clot buster. The newspaper write up stated that patients were given aspirin following their heart attack. Perhaps the newspaper reporter did not inquireif the patient then had to wait for a consultant to arrive and certify the use of the IV clot buster.

So while the door to aspirin time could have been short and commendable, the door to needle time is probably long. Aspirin, on it's own, without the use of the IV clot buster, opens the heart artery unreliably, and certainly is not standard cardiac therapy in an acute heart attack. What is even more important is that in the 21st century, a good tertiary cardiac care center would have a well equipped and well trained cardiac cath lab and team, to perform immediate angioplasty for the heart attacks.

Giving just sublingual aspirin alone, is poor therapy. Giving IV clot busters with aspirin is reasonable therapy (particularly in hospitals without a trained angioplasty team). The best therapy, especially an award winning therapy should be immediate angioplasty especially in a good tertiary care center.

Dr Jeyaindran and his team should be commended for their tremendous effort to improve the standards of care for heart attack patients. Beyond this achievement there is still a long way to go, how far this is we will leave you to judge for yourself.