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.