Raising awareness of STEMI/PPCI protocols: Part 1

Every year I go to  churches, seniors centres, curling rinks, legions, adult condominiums and teach CPR to hundreds of older adults. Whenever I work with this age cohort a large portion of class time is inevitably dedicated to discussing Heart Attack recognition and management. Considering how many of their tax dollars have been used to study and treat Myocardial Infarction (MI) and how close to home MI hits for virtually everyone in room I am always a little saddened by the misinformation and lack of awareness most people are burdened with.

We usually begin with a discussion of signs and symptoms and of course we always talk about gender differences in the presentation of MI. In this demographic there are usually one or two people in the room who are willing to share their firsthand experiences with the class. Sometimes their story's leave us all near to tears and sometimes we end up having a little laugh, but these shared experiences always bring the reality of MI directly home.

Once we've established what it is we're looking for I ask the question "What should you do when you see it?" It is at this critical fork in the road that virtually everyone I have ever taught starts making bad decisions; ill informed, poorly thought out, life threatening decisions.

It is my experience that folks in Ontario, and I'll go out on a limb and suggest people everywhere, know almost nothing about advancements in the treatment of Heart Attack. In Ontario there are 14 Cardiac Catheterization Laboratories (Cath Labs) insuring that the majority of the provinces 12 million residents have access to Primary Percutaneous Coronary Intervention (PPCI) for ST-Elevated Myocardial Infarction (STEMI) within the 90 minute timeframe that produces the best possible outcomes.

My next questions is often "What hospital does this person need to get to?" and with unanimity the class names the closest hospital. Then I might ask "How would you get your spouse to the hospital?" and too many of the men and even some of the women suggest that they would drive their spouse as it is only a few blocks and they would "get them there much faster than EMS ever could". My next question is "Which hospital in this regions specializes in the treatment of Heart Attack?" One or two confident and one or two timid voices give the correct answer. And then you can hear pennies dropping all over the room as one by one by one they realize that their job is to get their loved one to the best equipped hospital with the best trained doctors as quickly as possible.

In Ontario, and likely where you live, every ambulance is equipped with an ECG monitor and every Paramedic is trained to use it. When you call 9-1-1 Paramedics come to your location and the first thing they do is hook the patient up to an ECG monitor and with impressive accuracy determine if the patient is having a STEMI, the type of Heart Attack that requires immediate transport to the Regional Cath Lab. When a Code STEMI is declared a highly skilled team of Paramedics, Interventional Cardiologists and Cardiac Nurses jump into action. The goal is to restore blood flow to the affected part of the heart within 90 minutes. When the PPCI procedure is completed within the 90 minute timeframe the results are impressive. Many patients are home within a few days with little or no permanent damage to their heart and little or no loss of heart function. Patients return to quality living and return to work very quickly and many claim to "feel better than they've felt in years" only a few short weeks after the event. Patients that hit the 90 minute door to balloon target are also far more likely to be alive five years after their MI.

These amazing outcomes are only achieved when;

• Chest pain, shortness of breath and sweating are recognized as a possible MI.
• The patient is quickly made comfortable and perhaps given aspirin (ASA) 
• 9-1-1 is called.

When the Paramedics arrive at the front door the 90 minute clock starts ticking and in most instances the Code STEMI Team beats the clock and the best possible outcome is achieved. But none of these good things happen when the people around the patient don't know how to recognize or respond to the warning signs of Heart Attack. Investment in Cath Labs and STEMI protocols should be matched by appropriate investment in community awareness.

Protecting Children from Sudden Cardiac Death

Over the past month my Google alert set for “Cardiac Arrest - Athlete” has informed me of six incidents involving young athletes dying during or shortly after physical activity. This is a typical month, perhaps even a little on the low side. Bear in mind that these diseases claim many more lives in non-athletic settings, we tend to only hear about the athletes because their deaths are so public. Dr. Andrew Krahn’s research showed two young person sudden cardiac deaths where physical activity was not a factor for every one where activity was noted.

Sudden Cardiac Arrest (SCA) is relatively rare in children but it does claim the lives of nearly 600 young Canadians each year. Most of these deaths occur in children that have an underlying heart rhythm disorder. Heart rhythm disorder is not one disease, but rather a group of diseases. Some diseases, such as Hypertrophic Cardiomyopathy (HCM), affect the muscle structure of the heart while others such as Long QT Syndrome, affect the heart’s electrical system. All heart rhythm disorders leave the child more prone to cardiac arrest and sudden cardiac death.

Many heart rhythm diseases are inherited or genetic. If your family has a history of unexplained early death, that is a warning sign. Look back several generations for deaths of relatives younger than age 35.  If you or your spouse had a history of fainting when you were younger, that is also a warning sign.

It is reported that 1 in 500 children worldwide are affected by a type of heart rhythm disorder.  What does that mean? It means that in a typical high school, there are two or three otherwise healthy kids living with a potentially lethal heart rhythm disorder. The majority of individuals and families are unaware of their condition.

For half of the children that die from these diseases the first warning sign is death, but for the other half there could be other warning signs that occur in the days, weeks or months prior to the cardiac arrest. The most common and easy to recognize warning sign is fainting. The majority of childhood fainting spells are innocent; however, fainting can be a warning sign of an underlying heart rhythm disorder.

Fainting as a Warning Sign

Be most aware of;

·        those that occur during or shortly after intense physical activity

·        those triggered by emotional distress or auditory startle

·        multiple fainting episodes

·        a child with both a personal and family history of fainting

Other Warning Signs:

·        Palpitations or feeling a “racy” heart

·        (New) Extreme shortness of breath during activity

·        Brownouts and/or dizzy spells

If your child has experienced any one of these symptoms, you should visit your doctor or paediatrician. Also, if there are others in your family who died at an early age for unexplained reasons, you should seek advice from a physician that specializes in heart rhythm disorders. Diagnosing these diseases begins with a complete event history of the fainting episode, a detailed patient medical history and a detailed family medical history. Typically two non-invasive tests, ECG and Echocardiogram, are ordered and often result in a definitive diagnosis. Less frequently further testing such as Stress ECG, Cardiac MRI and Genetic Testing are required.

Two very positive things happen if your child is diagnosed with a heart rhythm disorder:

1.      There are a number of therapies which are highly effective at reducing your child’s risk of sudden cardiac arrest. These include surgical options, implantable devices such as pacemakers and ICD’s, pharmaceutical therapy and life style modification. Many patients get excellent protection from cardiac arrest by simply taking a low dose beta blocker. Once on a treatment plan most children can reasonably expect to live long, healthy and productive lives.

2.      Often one diagnosis leads to several family members being diagnosed. When one member of your family is diagnosed doctors will begin testing other family members including siblings, parents, grandparents, aunts, uncles and cousins. Again the good news is that these relatives will also begin treatment that will reduce their risk of cardiac arrest.

Sudden cardiac arrest in young people is a rare occurrence but knowing and responding to the warning signs has the potential to save hundreds of young lives each year. Children that are being treated for a heart rhythm disorder should live long and healthy lives.

When children faint, see a Doctor.

 

Cancel One Game

In my community of about a half million residents I am aware of four cardiac arrest events in the past decade where an Automated External Defibrillator (AED) was nearby and no one knew it was there, or how to use it, or both. In all four incidents the patient was an adult participating in sport; two playing soccer, one playing hockey, one refereeing hockey. In all four incidents the patient died.

In all four cases the town had purchased and installed AED's at the facility where the event occurred and had trained staff in CPR and proper AED use. In our town, as in most places I suspect, staff are not always highly visible when adult sport leagues are using the gyms, diamonds, fields and rinks and there is no reason why they should be.

Anger, frustration, blaming, fingerpointing were rampant after each of these tragedies. Family, friends and teammates of the deceased lamenting that someone should have done more. And of course they are right, someone should have done more and that someone was them. If 12 grown men are playing basketball in a school gymnasium at 10:00 pm and one of them collapses, and none of the others know CPR and none of them know that there is an AED in the hallway just outside the gym and no one can find the night custodian (who is legitimately performing his job in another part of the school) and the best anyone can come up with is "Call 911" and their buddy dies without receiveing even one effective chest compression or a single shock from an AED, the responsibilty for the lack of a reasonable resuscitation attempt rests solely with the other 11 men.

After the anger and frustation abates and the lawyers explain why a lawsuit is unwinnable, the guilt and the "if only's" set in and hang around for a long long time. Watching someone you care about die and thinking to yourself  "If only I'd taken that CPR course, maybe I could have made a difference" is a curse I would not wish on any person.

The solution is simple Cancel One Game. If you are actively involved in any adult sport league ask the other athletes in your league if they would be willing to Cancel One Game in 2013/14 and take a CPR/AED course instead. Simply Google "CPR" to find a local training agency and have an instructor come out to your next game night and teach these life saving skills to all of the members of both teams.

If every adult recreational sports league across the country partcipates in the Cancel One Game initiative over the next three years by 2016 there will be a statistically significant increase in survival rates for out-of-hospital cardiac arrest in most communities. Consider that the skills learned in a CPR class, including how to recognize and respond to heart attack and stroke, go with you wherever you go, to work, to the mall, to a family get together. Consider too that the number one contributing factor when people do survive cardiac arrest is bystander involvement. Most cardiac arrest survivors benefit from quality CPR and an AED being administered prior to the arrival of professional responders.

In 2013/14 talk to your teammates and agree to Cancel One Game, to learn CPR, how to use an AED and how to recognize Heart Attack and Stroke. When the day comes and you need these skills you will be glad you did.