Six hours. For years, that was the time window for removing a blood clot in a stroke victim. Go beyond that six-hour mark and the benefits decrease dramatically, physicians believed. But in January 2018, the American Heart Association and the American Stroke Association released new guidelines with a new time window: 16 to 24 hours, depending on the patient.
The decision was based on two studies led by Stanford University Medical Center and the University of Pittsburgh Medical Center (UPMC), with the participation of dozens of teaching hospitals. The idea, however, came from discussions that occurred almost 10 years earlier at UPMC.
“It’s been a labor of love,” says Tudor Jovin, MD, assistant professor of neurology and neurosurgery at the University of Pittsburgh School of Medicine, who was a principal investigator for one of the trials and currently serves as director of UPMC’s Stroke Institute. (UPMC had the largest number of patients in the trial.) “We encountered a lot of resistance because people didn't believe that these trials were feasible — that they would show what we thought they would show. There was a lot of skepticism.”
Jovin’s comments underscore why medical schools and teaching hospitals are known for medical innovation. Not only do many of them offer the latest treatments and cutting-edge technology, they frequently house world-class research facilities. And they employ a range of experts, from experienced biomedical researchers and clinicians, to students, residents, and fellows, all of whom bring a unique perspective to the work.
“You get the innovative thoughts of new doctors with the experience and wisdom of those who have been doing research for a long time,” says Mona Bahouth, MD, assistant professor in the department of neurology at Johns Hopkins School of Medicine. And that, she says, results in challenges to the intellectual status quo.
Indeed, teaching hospitals have a history of innovations that have dramatically reduced mortality from heart disease and stroke. Between 1969 and 2015, deaths from heart disease declined 68%, due in part to research funded by the National Institutes of Health (NIH) and conducted at medical schools and teaching hospitals around the country. Here are some of those key contributions.
Since 1950, 80% of the Nobel Prize winners related to cardiovascular disease have been affiliated with American medical schools and teaching hospitals. Among the achievements: Biomedical researchers at academic medical centers helped show that treating even moderate hypertension reduced cardiac-related deaths. Research pioneered at medical schools and teaching hospitals also led to new standards of care for treating coronary artery disease and new medical and surgical treatments.
The work of one institution often leads to developments at another. Two medical professors at Columbia University won the Nobel Prize in 1958 for discoveries related to heart catherization. That research led the Cleveland Clinic and the University of Oregon to conduct pioneering work on coronary angiography in the 1950s and ‘60s, although it was “an accidental discovery,” says Joaquin Cigarroa, MD, head of the Oregon Health & Science University School of Medicine’s (OHSU) division of cardiovascular medicine. In 1958, F. Mason Sones Jr., a pediatric cardiologist at the Cleveland Clinic, was conducting a cardiac catherization. As his resident injected 50mm of dye into a patient’s aorta, the catheter moved slightly and some of the dye inadvertently entered a coronary artery.
“That began the era of consistent angiography,” says Cigarroa.
At OHSU, in 1964, Charlie Dotter became the first physician to perform an angioplasty on a peripheral artery. The patient was an 82-year-old woman suffering from blocked circulation in her leg. Physicians wanted to amputate, but she refused. A surgeon knew Dotter, who used a guide wire and Teflon catheters to dilate a superficial femoral artery stenosis.
“He demonstrated that you could actually push aside plaque in an artery,” says Cigarroa.
Between 1969 and 2015, deaths from heart disease declined 68%, due in part to research funded by the National Institutes of Health (NIH) and conducted at medical schools and teaching hospitals around the country.
Researchers working at medical schools and teaching hospitals have also helped develop everything from less-invasive angioplasty procedures to robotic surgery to surgeries that don’t require stopping the heart or using a heart-lung machine. Physicians at OHSU, Harvard, and Georgetown, among others, have developed and improved artificial heart valves. Procedures pioneered at teaching hospitals — including the Cleveland Clinic and Stanford — led to the development of Transcatheter Aortic Valve Replacement (TAVR), which allows physicians to treat aortic stenosis without open-heart surgery and often without long-term recovery. Middle school teacher Susan Strong, who underwent TAVR surgery at the University of Colorado Hospital in 2014, notes that she attended a full-day seminar one day after the procedure.
Researchers working at medical schools and teaching hospitals have also played a critical role in developing heart transplant surgeries and ventricular assist devices. The first such device was implanted by faculty members at the Baylor College of Medicine. At OHSU, researchers are currently working on an artificial heart designed for permanent use. (The only patented artificial heart is for temporary use.) The device would replace two ventricles with a single titanium tube. A rod in the tube moves back and forth to send blood to the lungs.
“It has gone through the engineering testing and we have done some short-term experiments,” says Cigarroa. “It shows promise, which is exciting.”
The groundbreaking studies published in 2018 that increased the window for life-saving clot removal surgery are the latest in a long history of improvements to stroke treatment. How much has changed? Since 1969, the stroke mortality rate has declined by 71%, due in large part to NIH-funded research on treatments and prevention conducted at medical schools and teaching hospitals.
In 1995, an NIH-funded clinical trial established the first FDA-approved treatment for ischemic stroke – the drug r-tPA (tissue plasminogen activator). Even more notable, clinical trials conducted in part at academic medical centers have established the importance of improved blood pressure control, decreased smoking rates and the use of statins in stroke prevention.
More recently, telestroke and teleneurology programs are making further inroads in reducing the death rate from stroke. Potential stroke victims need specialized expertise within hours of experiencing symptoms, but that can be difficult in rural areas. In the Stroke Belt — an 11-state region consisting of Mississippi, Tennessee, Louisiana, Kentucky, Georgia, North Carolina, Alabama, South Carolina, Arkansas, Indiana, and Virginia — stroke rates are 34% higher than in other parts of the country, the CDC reports. Because of that, many teaching hospitals provide access to experts through audio and video links.
After speaking with patients and reviewing medical records and imaging and lab results, physicians can determine if the stroke is ischemic or hemorrhagic, offer advice on whether to use the emergency stroke drug r-tPA, and recommend whether a patient should be sent for surgery. The many teaching hospitals that provide telestroke and teleneurology include Emory University Hospital, the Medical University of South Carolina Medical Center, Nebraska Medicine, the Ohio State Heath System, the Ronald Reagan UCLA Medical Center, and Yale New Haven Health. The University of Utah Health System provides telestroke services to more than 25 sites in Utah and elsewhere. And Penn State Health Milton S. Hershey Medical Center partners with regional hospitals for its telestroke program, called LionNet.
“At our core is a mission to advance gaps in knowledge that can impact patients. That is done at a basic science level, through clinical trials, through innovations in how we teach, and in partnership with communities. It is who we are.”
Joaquin Cigarroa, MD
Oregon Health & Science University School of Medicine
The Cleveland Clinic is reaching stroke patients through its Mobile Stroke Unit, an ambulance-like vehicle with staff, equipment, and medications for diagnosing and treating strokes. The vehicle also includes a lab to test blood samples, a portable CT scanner that can send images to the hospital, and a telemedicine link to the hospital’s neurologists. A 2017 study in Neurology found that patients received thrombolysis 38.5 minutes sooner via the Cleveland Clinic’s mobile unit than they would with traditional stroke procedures. The University of Texas Health Science Center at Houston (UT Health) introduced the first Mobile Stroke Unit as part of a clinical trial in 2014; others with units include the University of Tennessee Health Science Center and Indiana University Health.
Medical schools and teaching hospitals have also been innovators when it comes to patient safety. In a recent study by researchers at UT Health, stroke patients treated at teaching hospitals were less likely to be readmitted than those who weren’t.
Other innovators are focused on recovery. Since 2015, the Stanford Stroke Recovery Program has focused on improving “gait, arm function, and cognition after stroke.” The laboratories have worked on new therapies, noninvasive brain stimulation, and medical devices. Among its more interesting trials: The program is testing the StrokeCoach, a rehab program that uses the Apple Watch to offer exercises and assess the progress of a weak arm following a stroke. It’s also testing devices to improve hand function and muscle weakness.
At Johns Hopkins, researchers are bringing together engineers, nurses, physicians, and other experts to create a treatment room that becomes “the treatment machine for a stroke patient,” says Bahouth. “Think of it as a bio room that measures and responds to patients’ needs. That will require a lot of innovative work between technologists, engineers, and informatics people, but I think that's where we're moving: To test a concept that creates a whole environment of healing for stroke patients.”
Innovative ideas like this are part of the DNA of teaching hospitals — and they will continue to save lives.
“At our core is a mission to advance gaps in knowledge that can impact patients,” says Cigarroa. “That is done at a basic science level, through clinical trials, through innovations in how we teach, and in partnership with communities. It is who we are.”
Roberta Shapiro also contributed to this story.