I was driving home a
fortnight ago when I was surprised by the sudden appearance of an ambulance
driving away from the house. I then drove to the emergency department only to
realise that my uncle had developed a massive stroke with confusion, inability
to speak and complete loss of power on one side.
The
ambulance team that arrived had acted with army-like precision and had whisked
him off. He was rushed into the emergency department where a team of doctors
swung into action with an efficiency that was marked by professionalism and
well-practised clinical routines. Speed was of the essence and hence, he
underwent computed tomography (CT) scan of the brain which confirmed that there
was complete blockage of the main arteries on one side of the brain as a result
of clots that had originated from the heart.
Not
known to anyone previously, my uncle had developed atrial fibrillation, an
irregular heart rhythm involving the upper chambers of the heart, causing the
blood flow to slow down significantly. The blood flow in the left upper heart
chamber had slowed down so significantly that blood clots had formed. The blood
clots subsequently travelled from the heart to the brain arteries cutting off
blood supply.
A remarkable outcome
The
neurologist proposed giving intravenous recombinant tissue plasminogen
activator (rtPA), a clot dissolving agent, but at the same time cautioned that
there was also a risk of worsening of the stroke if the rtPA caused bleeding
into the brain. If there was bleeding into the brain, the likelihood of a fatal
outcome will be very high. Despite the risks, the decision was taken to proceed
with the immediate administration of rtPA as the stroke was massive and was
likely to be life-threatening.
I
heaved a sigh of relief when an ultrasound Doppler scan (using sound waves to
detect blood flow) of the blocked brain artery performed within an hour showed
that flow had been restored. By next morning, my uncle could move his
previously paralysed limbs and was able to respond verbally. Amazingly, he was
discharged last Sunday with virtually full recovery.
Advances
in medical science and highly trained medical professionals can make the
difference between life and death. The administration of the clot dissolving
drug within two hours of the onset of acute stroke had brought my uncle from
the brink of death to full recovery. It was a remarkable achievement by the
team of doctors who cared for him.
Dissolving clots in
brain arteries
As
early as 1996, the US Food and Drug Administration had approved intravenous recombinant
tissue plasminogen activator (rtPA) as a treatment for acute stroke resulting
from blockage of the brain arteries. Its approval was largely based on the
National Institute of Neurological Disorders and Stroke (NINDS) rtPA stroke
trial that showed treatment with intravenous rtPA within three hours of the
onset of stroke symptoms led to an overall 32 per cent relative increase in the
proportion of patients with minimal or no disability after three months.
However,
rtPA was associated with 6 to 8.8 per cent risk of bleeding in the brain which
was often fatal. The magic hour is "3" and the American Stroke
Association/American Heart Association guidelines recommend that rtPA be
administered within three hours for suitable patients with acute stroke.
Clearing clogged
heart arteries
The
benefits of administering clot-dissolving agents to dissolve blood clots in
arteries has long been established for acute heart attacks since the 1980s.
Since then, most patients with a sudden heart attack who are brought to the
emergency department are given clot-dissolving agents.
At
hospitals which have the resources, patients who are seen in the emergency
department with a heart attack are sent to the heart department where teams of
highly trained heart specialists work to open their heart arteries with
"balloons" and stents (cylindrical metallic meshes used to open heart
arteries) in the shortest time possible. These developments are embodied in the
latest 2011 guidelines of the American College of Cardiology Foundation and
American Heart Association which recommend that the blocked artery responsible
for the acute heart attack be opened within 12 hours of a major heart attack.
Beating the clock
Treating
sudden strokes and sudden heart attacks by teams of highly trained specialists
in the shortest time possible has enabled many lives to be saved. The provision
of such services means that significantly more manpower resources are required
including getting specialist doctors and their teams to come in at any time of the
night in the shortest time possible to do the best for their patients. The
reality is that not all hospitals have these resources.
For
those who are suspected to be in the throes of an acute heart attack or acute
stroke, time is of the essence and they should get to the emergency department
in the shortest time possible. However, sometimes getting there in time may not
be enough.
This
same fortnight, a patient related to me the unfortunate outcome of his relative
who had developed sudden chest pain and had reached the emergency department by
taxi. His relative walked in to register himself but had to wait in queue to
see a doctor as the emergency department was extremely crowded and the staff
was unable to differentiate between the severity of his case and others. Within
10 minutes of waiting, he collapsed and could not be revived as he suffered a
massive heart attack. The autopsy showed severe blockage of all his three major
heart arteries.
If
you have reason to believe that one of your family members has an acute stroke
or acute heart attack, calling the ambulance will not only ensure that the
highly trained staff can attend to him quickly but their assessment will ensure
that if he has a medical emergency, he will be immediately attended to upon his
arrival in the hospital without any delay.
Dr
Lim is medical director at the Singapore Heart, Stroke & Cancer Centre. He
is also editor-in-chief, Heart Asia; British Medical Journals Publishing Group,
chairman; Scientific Advisory Board, Asia Pacific Heart Association honorary
professor and senior medical adviser, Peking University Heart Centre.
This
series is brought to you by the Heart, Stroke and Cancer Centre. It is produced
on alternate Saturdays.
Dr
Michael Lim
The
Business Times
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