Transcriber: Zane Mitrevica Reviewer: Denise RQ
Today I'm going to talk about a very scary symptom,
acute chest pain,
something that can happen any time of the day,
and get you rushing to the emergency room by whatever means necessary,
maybe, perhaps, even by a helicopter.
In fact, this happens 6 million times a year throughout the United States,
costing the healthcare system over 15 billion dollars
to take care of this single diagnosis.
And most of the money is really spent on
making sure that you're not having a heart attack.
And can we do something better to improve this process?
Can we save money and save the pain
that the patient has to go through for this very uncomfortable condition?
But before we go there, let's talk about what is acute chest pain,
or the medical term angina.
It is pain that's spread from the chin to the belly button.
It can radiate or travel to the shoulder, to the back.
It's very unpredictable.
There are other life-threatening causes of chest pain, equally deadly.
One is acute pulmonary embolism, blood clots in the lung.
The other one is rupture of the main vessel in your chest,
or aortic dissection.
These are all chest pains.
How can you distinguish one from another?
There are also many chest pains that are completely benign:
gas pain, indigestion,
pinched nerve, muscle soreness, to name just a few.
How can you distinguish one from another?
How do you know for which one you need to go to the emergency room,
and for which one you don't?
The short answer is that you can't tell.
And that's why there are 6 millions ER visits a year.
I remember the process that evaluates patients
when they come into the emergency room with chest pain;
this has been going on for over 27 years.
I still remember vividly the case
that I took care of when I was a student.
A 40-something businessman came into the emergency room
in the middle of the night, woke up with chest pain.
He thought he was having a heart attack.
We immediately escorted him into the emergency room,
put him on a stretcher.
We did blood tests, we did EKG.
In fact, we did it again and again.
We kept him on a stretcher in a busy emergency room,
right next to many other sick patients.
And we kept him there for hours.
And after about 12-13 hours, he said:
"My pain is gone, I want to go home."
I said: "You can't, we aren't done yet. We need more blood tests."
He decided to sign out against medical advice.
And I told him not to do that.
He said: "Well, I'm fine, I'm going home."
So as I was preparing the papers,
the last blood test came back
that showed that he was having a heart attack.
I told him that, "No, you can't go home."
So he turned around, we admitted him to the coronary care unit,
and he subsequently had a procedure
that opened the blockage in one of his main coronaries.
This scenario has happened again and again
for the past 27 years throughout the United States.
What is a heart attack?
We need to understand that process in order to make a difference,
to change the process that evaluates this deadly condition.
Heart attack basically is a result of plaque build-up
in your heart vessels
over a period of decades.
It's very unpredictable who's going to get it early,
and who's going to get it late.
We have seen young people in their 20s having heart attack,
and we have seen 80-something grandma with clean coronary.
Go figure.
The short answer is you cannot tell
just by judging the look of an individual.
You need something more advanced.
And when you have a heart attack
that's the end of the disease build-up.
It's like a volcano rupture,
and a sudden stoppage of blood going down to the muscle.
That's what you're feeling,
you're feeling the pain of the muscle dying.
And that's why we are doing blood tests, we are doing EKGs
to detect any electrical instability going on in your heart.
If you survive the ordeal of waiting in the emergency room for 14 hours,
you think that that's the end.
Well, you haven't seen the second act yet.
Basically what the blood test and EKG have done
is proving you're not having a heart attack,
but that doesn't mean that you're not going to have one
within the next few days, or months.
So oftentimes you need to go through the second level of tests,
and there are two that we often execute.
One is stress test, the other one is invasive coronary angiography.
They are performed to make sure
that you're not going to have a heart attack in the near future.
Well, a lot of hospitals decided not to do the stress test;
they just ask you to go see your doctor within the next three days.
To me, that's like playing Russian Roulette.
And there are some hospitals that would do angiograms
to just make sure it's ok,
so many patients went through
that invasive, potentially deadly procedure for nothing.
So there has to be a better way to do this.
And these two tests turn positive
only if you have a severe lesion,
and they completely ignore a whole group of patients
with early and mild diseases,
which, I think, is a missed opportunity,
and we need to do better than that.
Well, at Stony Brook, since I came here 5 years ago,
we pioneered a whole new approach.
We said that the standard of care is time-consuming, costly, inaccurate,
and oftentimes the patient is sent home
with a false sense of security that there's nothing wrong with the heart.
That's far from the truth.
As I showed you in the cartoon before,
many patients with early diseases -
[we should be able to] do something about it,
Aad we cannot miss this golden opportunity.
So what is this new strategy?
It involves modern technology,
a CAT scanner that can freeze the motion of a beating heart.
For the first time, we can get a picture
of the heart and its blood vessels
in less than one second.
That change makes a big difference
in terms of what we can and cannot do.
So for the past 5 years,
we've been using this approach to evaluate the patients.
Just look at this cartoon.
The difference with the CAT scan
is that we see the entire spectrum of the diseases,
the entire spectrum of the plaque build-up process.
We have a lot of patients with normal diseases
that go home and feel safe, and they don't have to come back.
And more importantly,
we help those patients with mild or moderate diseases
to recognise that they need to do something with their lifestyle,
and perhaps they need to work with their doctor
to modify the risk factor.
Are they sedentary? Are they smoking too much?
Is the blood sugar too high? Is the cholesterol too high?
All of these things need to [change]
once you know that you have early signs of plaque build-up.
To me, that is the most important piece of information we could gather
from this technology.
Furthermore, this test is not only for the heart.
We could detect
the other two deadly conditions that I talked about.
Pulmonary embolism? No problem. We pick that up right away.
Or the rupture of a blood vessel. We do that equally well.
And for those with clean coronary,
no problems to the lung and the aorta,
they can be sent home
rest assured that nothing's going to happen within the next 6 months.
That's a pretty good warranty period for diagnostic test in the emergency room.
So our data basically have shown
that this test is equally effective from infant to the elderly.
We have shown that it's equally effective
for women with small coronary vessels,
we're able to detect the subtle changes just as well.
And many patients who are morbidly obese
oftentimes need to be admitted.
Now we can use the CAT scanner and see the same thing,
and we can make a diagnosis equally well in this group of patients.
Our data have been quite convincing so far
that this is the most accurate and definitive way
of evaluating someone with acute chest pain.
We dramatically reduce the unnecessary hospital admission
from over 40% to below 10%.
And we also dramatically shorten the length of stay in the emergency room
from over 14 hours to less than six.
So you don't need to have
this painful long waiting period in the emergency room.
Once the scan is complete, if it's negative, you go home,
and you don't have the false sense of security either.
By knowing what you have, we found
that most of the patients don't even come back to the emergency room anymore.
The revisit rate dropped dramatically.
Well, what can we do better?
There's disruptive innovation,
something that we all aspire to achieve.
What is disruptive innovation?
Basically, innovation that's going to disrupt the status quo
for the betterment of the future.
So you want to disrupt whatever people feel comfortable doing
because that's not the right thing, it's outdated.
Well, we ask a very simple question:
Can we offer this service to another hospital
that does not have the capability, the resources,
yet can perform and offer the same beneficial service
to the patients who live around that area?
Well, the simple answer to this question
is the resounding yes, we have done that.
For the past two years, we've been working with J T Mather Memorial Hospital,
which is about 8 miles from here,
we helped to train the staff,
we've remotely helped them to scan the patient,
we've remotely interpreted the study for them,
and the patient can be sent home from the hospital immediately afterwards.
And our data shows that we're achieving the same outstanding outcomes.
80% of the patients can be sent home right away from the emergency room;
no more painful waiting in the emergency room hours to end.
And those patients with diseases, we detect them right away,
and transfer them back to Stony Brook for further advanced treatment.
It's a win-win situation for everybody.
And we also found that the images quality,
even performed remotely, are just as good.
We have no non-diagnostic images,
because the physician is actually involved with the data acquisition,
which also further reduces the radiation dose exposure,
and technicians feel a lot more at ease
that now they have a physician helping them to get good quality data.
So there's no downside to this disruptive innovative idea.
I hope that in the past 15 minutes or so
I was able to convince you
that we have now developed a way
to evaluate this condition more effectively.
Acute chest pain is no longer a lengthy,
painful, costly emergency room visit
because we have a way to make a diagnosis accurately.
And from a population health standpoint,
- I think this is the most exciting part
of this work that I've just mentioned to you -
we're able to identify an entire group of patients
in the past, or even in the present,
patients who went to other hospitals
besides Stony Brook and J T Mather,
that all got sent home with this false sense of security
that there's nothing wrong with their heart.
For this group of patients with mild and moderate diseases
we're going to make a difference in their lives,
we're going to change the natural history of the disease process,
and I believe, in the long run, we will save
many, many unnecessary heart attacks and sudden deaths.
So this imaging technique is transformative,
it's safe, it's cost-effective;
it also reduces the crowding in the emergency room.
Nobody wants to walk into a crowded emergency room,
and certainly you don't want to wait there for nothing.
The standard of care approach is time-consuming and not accurate,
and using the advanced information technology,
and telemedicine,
I believe that we can disseminate this expertise
to other hospitals
both locally and nationally.
We need to share this
because I think that's the only way
that disruptive innovation can ultimately reduce
the cost of healthcare,
so that other new technology can come out
to benefit more people.
If we keep doing the same outdated things, we're not going to advance.
By saving money
from outdated procedure and intervention,
that's how we make room for new technologies.
With that, I thank you for your attention.
(Applause)