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New Procedure Chills Heart Victims, Prevents Brain Damage

Cooling patients after heart attack or stroke helps save patients who would have died.

James Wark, age 59, was sharing commercial real estate tips with an audience of 120 people at a Houston seminar last November when he collapsed mid-sentence.

Quivering uncontrollably in ventricular fibrillation, Wark’s heart had stopped pumping.

But thanks to a radical procedure that literally chilled his body and brain for 24 hours, Wark later walked out of the hospital a new man.

To look at the lanky 6-foot-5 Texan today, “you would never be able to tell he had a heart attack or a stroke,” says Edward Escobar, M.D., his neurologist. When Escobar sees Wark, he sees “someone who was as close to death as one can be” who is back, alive and well.

“I feel a lot better now,” says a smiling Wark, who dabbles in acting in addition to real estate investment, building demolition and electronics recycling.

Wark’s story, with its hint of being raised from the dead, is no longer an anomaly: More and more hospitals across the country are adopting the treatment that brought him back to life.

For Wark, his second chance began when paramedics used CPR and a defibrillator on his heart, and then, in the ambulance on the way to the hospital, shot him full of chilled saline solution. When he arrived at the ER, doctors worked to stabilize Wark’s failing heart—it stopped nine more times at the hospital—and carefully wrapped him in large cooling pads to bring down his core body temperature.

As Wark lay encased in the pads, doctors gave him an injection that temporarily paralyzed his muscles to prevent him from shivering—a natural defense that raises the body temperature. And there he lay, literally chilling out at 92 degrees Fahrenheit for 24 hours.

Then, very gradually, doctors began to allow his temperature to rise again.

Wark and Escobar credit therapeutic hypothermia—the intentional lowering of a patient’s core body temperature—with protecting his brain, heart and other organs after his cardiac arrest. For years, doctors believed that if the heart stopped for more than six to 10 minutes, the brain was dead. Now more and more hospitals in the United States—including the University of Chicago Medical Center, Johns Hopkins in Baltimore, and Mount Sinai Medical Center in New York—are using this treatment, which can bring a patient back to a healthy life even if the heart stops for a period of time.

It used to be that few patients survived out-of-hospital cardiac arrest, which usually results from a massive disruption of the heart’s rhythm. Of the estimated 300,000 people who suffer cardiac arrest in the United States each year, fewer than 10 percent survive. And even with the best treatment—shocking the heart back to a normal rhythm and administering drugs like atropine and epinephrine—many survivors never fully recover.

That’s because once blood flow has been restored, oxygen-deprived cells release chemical distress signals that trigger further organ damage throughout the body. But researchers have found that lowering a patient’s body temperature to 89 to 93 degrees Fahrenheit inhibits this wave of cell death.

One new technique, plenty of luck

Wark’s case is a dramatic example of the stars aligning perfectly, with a chain of capable emergency paramedics and caregivers who each did the right thing—and did it promptly. But the final piece of luck was that Wark, at his wife’s request, was taken to nearby West Houston Medical Center, which had the hypothermia treatment. At West Houston, doctors and nurses cooled his body for 24 hours. He was so sick that they had to restart his heart more than a half a dozen times, and he suffered a small stroke. His family was told that if he survived he would likely suffer permanent brain damage. A priest administered last rites.

“Traditionally, these patients would pass away within 24 to 48 hours,” says Raina Merchant, M.D., a Robert Wood Johnson clinical scholar and emergency physician at the University of Pennsylvania who has extensive experience with hypothermia.

“Now, we’re cooling them down, and some of these patients are waking up,” she says. They go back to their families, even return to their jobs, and call “to tell us thank you.”

And, she adds, not that many medical procedures “are so life-and-death-changing. It’s really rewarding.”

Wark “woke up” from his cold sleep four days later and didn’t remember any of the drama. Weeks later, after bypass surgery and rehab, he walked out of the hospital and resumed his life.

Persuasive studies

The latest analysis of studies, released October 6, looked at nearly 500 patients who suffered cardiac arrest, underwent CPR and had their hearts restarted. It found patients who are cooled within six hours are 40 to 80 percent more likely to leave the hospital without a major handicap after cardiac arrest than those who don’t have the therapy. The researchers with the Cochrane Collaboration, a nonprofit that evaluates medical research, found no evidence of increased side effects.

Lead author Jasmin Arrich, M.D., of the Medical University in Vienna, Austria, said the technique "is one of the most successful treatment options for patients after cardiac arrest."

But the therapy’s effectiveness has been known for several years.

Two landmark studies of the hypothermia treatment in cardiac arrest patients reported in 2003 in the journal Circulation proved so persuasive that in 2005, the American Heart Association recommended chilling as standard treatment for out-of-hospital cardiac arrest.

In those European studies, 55 percent of the patients who had been cooled down for 24 hours were living on their own six months later, compared with 39 percent of a group who received conventional treatment. And in a study of 67 cardiac arrest patients in Melbourne, Australia, 49 percent of those cooled for 12 hours survived, compared with 42 percent of those were not.

And its cost is reasonable.

Merchant of the University of Pennsylvania recently studied the cost-effectiveness of hypothermia treatment and found the procedure compared favorably to many accepted medical therapies.

"Actual hypothermia is very, very reasonable," Merchant says. She points out that most emergency rooms already have cooling blankets used for heat stroke victims. The real expense, if any, comes later, when some patients need to go through rehabilitation therapy.

Hospitals slow to adopt

Despite success stories and convincing studies, many physicians still are not routinely treating cardiac arrest with hypothermia. A 2005 survey found that as many as 70 percent of U.S. emergency department doctors were not yet using the protocol.

Steven Brooks, M.D., an assistant professor in the department of medicine at the University of Toronto, published a paper last year contending that many doctors are slow to adopt new techniques for what amounts to cultural reasons. Among the barriers to changing attitudes are pessimism about whether the technique will work, doubts about the supporting research and the inertia of previous practice, he found.

"It's well recognized that physician and health provider behavior is hard to change," Brooks says. Many medical professionals see too few of these cases to develop expertise in treating them with hypothermia, he adds, and some are simply "bombarded" with new treatments for other diseases.

An alternative might be to create regional hypothermia centers—similar to trauma and stroke centers—where cooling equipment and medical expertise can be concentrated, Brooks suggests.

In some cities, hospitals are bolstering their hypothermia programs because they don't want ambulance crews to pass them by when they're transporting cardiac arrest patients, says David Beiser, M.D., an emergency physician and hypothermia researcher at the University of Chicago.

"It seems like this year it's beginning to get a lot of traction," says Beiser, who has been receiving more frequent invitations to talk about hypothermia with doctors and nurses. "We're transforming a culture of hopelessness to a culture of hope."

Meanwhile, scientists are studying cellular signaling pathways to better understand hypothermia's protective effects, Beiser says. While cooling slows a patient's metabolism, there may be other mechanisms at work. "Hypothermia is a fairly blunt tool, and it does a lot of things," he says. "I don’t think there's going to be one thing that’s responsible for the benefit that we see."

A fresh start

Last February, James Wark paid a return visit to the Wealth Club of Houston, where he had been speaking when he had his attack. He received a round of applause. "I was basically the only speaker that had dropped dead in front of them and come back to life," he says. Wark says he has quit smoking, is eating more vegetables and has adopted a more positive, health-oriented outlook. He is grateful to everyone who helped him survive and hopes that the experience his doctors gained in treating him will help other patients.

"Every day is a fresh start," he says. "I thank God that he still wants me around."

Michael Haederle is a freelance writer whose work has appeared in People, the New York Times and the Los Angeles Times.