Two Cost Comparison’s for Cardiac Arrest Prevention Programs

 

Brock Reuther died as a result of a sudden cardiac arrest experienced while playing volleyball at his Alberta High School in May of 2012. Since that day Brock’s mom Kim has been advocating for programs to prevent other families from experiencing the pain the Reuther’s have gone through and it has been, to say the least, an uphill battle.     http://projectbrock.com/

I was speaking with Kim this week and shared with her two comparators that I often use when speaking about preventing sudden cardiac arrest in youth. She asked if I could send them to her in writing so here they are.

The HPV (Gardasil™) Vaccine vs. ECG Screening for Heart Arrhythmia

In August of 2007 the Government of Ontario announced it would spend $39 million to provide every Grade 8 girl in the province with the vaccine for Human Papillomavirus (HPV) which is known to be a cause of many cervical cancers. That works out to a little over $400.00 per child. Cervical cancer claims the lives of 150 women of all ages in Ontario each year and is the second most common type of cancer in women between ages 22 and 44.  This is an expensive but worthwhile prevention program that will assuredly save young lives.

For many years patient advocate groups in Canada have been seeking funding and support for a pilot study into ECG screening of young teens. Many advocates would like to see the screening process include Echocardiogram as well. Published studies show that ECG alone can be over 80% effective at identifying children at-risk for sudden cardiac arrest and when Echo is added screening will identify over 90% of those at-risk.  The tests are non or minimally invasive and very inexpensive. The Ontario Health Insurance Plan billing code for an ECG to be acquired and read by a physician is $11.05. A targeted Echo is a little more expensive at $33.50.  For 10% of the cost of an HPV vaccine we could protect all young people from a far more prevalent and preventable cause of death – Sudden Cardiac Arrest.

A $250,000 grant would easily fund a pilot study that could gather, study, analyze, weigh the values and publish the results of screening tests for over 5,000 youngsters. Every year 700 young people die suddenly of cardiac causes in Canada - 200 in Ontario, 65 in British Columbia, 60 in Alberta, etcetera.   An ECG/ECHO screening program for teenagers is relatively inexpensive and assuredly would save hundreds of young Canadians from sudden death.

Note: ECG screening of elite athletes in northern Italy has reduced sudden cardiac arrest deaths in that population by 89%.

Anaphylaxis Awareness vs. Sudden Cardiac Arrest Awareness

In the spring of 2012 I gave a talk on Recognizing and Managing Cardiovascular Emergencies to 250 Human Resources professionals from across Ontario. A portion of the talk included a discussion of cardiac arrest in youth.

·        I asked for a show of hands to the question “How many of you know that you cannot send a child to school with peanut products in their lunch?”

o   Virtually every hand in the room went up.

·        I then asked “How many of you know that “fainting” is a common warning sign of a potentially lethal heart rhythm disorder?”

o   Perhaps 10 hands went up.

·        I then asked “How many kids in Ontario will die this year from peanut allergies?”

o   The answer is probably none, perhaps one and if it is a very bad year two.  Note : 2 deaths in ON since 2010

·        Finally I asked “How many young people will die in Ontario this year as a result of Sudden Cardiac Arrest?”

o   The answer is 200 – a palpable buzz went through the room.

It is fantastic that the Provincial Government and the School Boards that it funds have invested so much money, time and effort into creating universal awareness and compliance for strategies for preventing two or three peanut allergy deaths each decade. It is frustrating and nonsensical that the same Government and the same School Boards have invested virtually nothing into awareness and prevention strategies for the most common cause of death on school properties and the most common medical cause of death amongst Ontario children.

Every patient advocate probably believes that research and programming for their disease is underfunded. Those of us working to protect the lives of children at-risk for Sudden Cardiac Arrest can look around and see tens of millions of dollars being spent on prevention strategies for diseases that cause less than 1% of the suffering brought on by Heart Arrhythmia Diseases. We would never want or ask Governments to cut back that spending, we are simply asking them to listen to our story and act on our requests for similar consideration. Again this year 700 young Canadians will die suddenly of cardiac causes, many of those deaths should be prevented.

A Five Point Cardiac Arrest Prevention Strategy for Canadian Schools

Here is an excerpt from an article written on research presented by Dr. Andrew Krahn at the 2012 Canadian Cardiovascular Congress.

“Our research gives us an idea of the scope of the problem – there are almost 200 young people who die suddenly every year in Ontario. A good proportion of them have unrecognized heart disease. So the question is: How can we catch this before it happens,” says Krahn.

He suggests that more attention be paid to possible warning signs such as fainting. He believes that teachers, coaches and an aware public may be key to detecting risk, ensuring prevention and formal medical evaluation and therapy.

“I would advocate for careful screening of people who faint, using questionnaires and education of healthcare professionals so that when warning signs present themselves, they recognize them and this information gets passed on to the right people,” he says.

http://news.bioscholar.com/2012/10/hidden-disease-sports-sudden-cardiac-arrest.html

With virtually no hard cost every School Board could implement Dr. Krahn’s recommendations for preventing sudden death in children. The five key elements of a Cardiac Arrest Prevention Strategy are: 

A 20 Minute Arrhythmia Awareness Training Program that provides some background on Inherited Heart Rhythm Disorders (IHRD) and explains the warning signs and how to respond appropriately to those warnings. It should be available on-line to all staff and families but should be mandatory for all staff taking AED/CPR certification training and for all Physical Education Teachers and Coaches

A Pre-Participation Screening Questionnaire that would be completed by all parents/guardians at the time of enrolment at a new school. When there are positive answers in both the patient history and family history sections of the questionnaire the family should consult a physician immediately.
http://leadingcause.blogspot.ca/2013/05/inherited-heart-rhythm-disorder-pre.html

Mandatory 9-1-1 Calling  for Loss-of-Consciousness Fainting (syncope) It may be mandatory 9-1-1 for all syncope or at the very least mandatory 9-1-1 for all syncope occurring during or shortly after physical activity. In most communities ambulance are equipped with ECG monitoring equipment and paramedics are trained in heart rhythm recognition. Our tax dollars paid for this equipment and training it only makes sense to use it. 

Mandatory Notification of Parents/Guardians of all Syncope including providing them with information about IHRD’s. Parent's must be informed on the day of the event and must be provided with information that will help them understand the significance of fainting and other warning signs and the importance of physician follow-up. 

Mandatory Medical Clearance for Return to Play Post Syncope Perhaps the most tragic teen deaths are those where there is one or more fainting episodes in the weeks or months prior and the child is allowed to continue to participate in physical activity and dies because of it.

Pennsylvania has passed a law that includes several of these elements. Many other states including Maryland, Ohio and Indiana have pending Sudden Cardiac Arrest Prevention Legislation. Ontario allowed a bill to die on the order paper and it has yet to be revived despite having unanimous support at first and second reading.

If provincial or state legislation is not pending in your jurisdiction go ahead and implement these policies and best practices in your School Board. Work together with local paediatric cardiologists/electrophysiologists to develop the messaging around warning signs. Work with local EMS and ER Physicians to develop policies and practices around 9-1-1 calling for syncope. Trust that mandatory 9-1-1 calling for syncope (especially a child's first faint) occurring on school property will not create an avalanche of unnecessary "nuisance" calls, it won't. Remember that Automated External Defibrillators don't always work, it is better to prevent cardiac arrest than to try and reverse it with an AED.

One in twenty paediatric faints are sinister (the good news is that 19 in 20 are benign) but that number goes up if physical activity was the obvious trigger.  From a risk management standpoint it makes sense to be proactive on fainting and for the well being of our children it is imperative that all fainting be investigated.

The Knowledge Trapped Inside an AED

Reading this awesome commotio cordis "save" story today reminded me of an issue that I have been raising for a number of years.

http://www.thecommunityvoice.com/article.php?id=6321

It seems counter intuitive, certainly to a lay person like myself, that an AED is far more likely to work on a 60 year old fan collapsed in the stands than on a 20 year old athlete lying on the field. It seems as if the younger (healthier?) heart should be a better candidate for a jump start. However the data is clear, in the two studies below no intercollegiate athletes were saved although several received a shock from an AED.

http://www.ncbi.nlm.nih.gov/pubmed/21081638
http://www.ncbi.nlm.nih.gov/pubmed/16177599

The obvious question is - Why?  Electrophysiologists have a pretty good understanding of why, or at least why they think AED's often don't work on young athletes. The word "acidosis" usually comes up, along with a number of other popular theories.

My first question is - Can we be doing more to understand what is happening to the heart of a young athlete that arrests during or shortly after intense physical activity?

My second question is - With greater understanding can we develop new algorithms for AED's and new protocols for trained responders that will result in higher survival rates for young athletes?

My third question is - Should we/us/somebody/anybody be setting up an event data registry, that includes the downloaded ECG data from the AED, for all cardiac arrest events involving young people.

Researching cardiac arrest in the adult population is simplified by the fact that researchers can acquire data from thousands of events quite easily. Cardiac arrest in young athletes is relatively rare so to acquire even 1,000 data sets, with ECG attached, is a challenge. If there were a central registry where defibrillation program coordinators, athletic trainers and first responders from across the country could send event data it would provide researchers with the horsepower they need to make meaningful determinations. Collecting the ECG data from every event occurring at elementary schools, high schools, colleges, universities, and community sport venues would, within a few years, provide thousands of records for researchers to consider

The AED captures the earliest presenting rhythm and is more likely to contain answers than ECG's acquired by paramedics or in the ER. If the first ECG is captured after ROSC is achieved there is no record of the presenting rhythm. Knowing exactly what's happening electrically to an athletes heart within the first moments after collapse seems to me to be the first step in figuring out how to improve outcomes.

If one good thing comes out of the death of a young person it may be that the ECG downloaded from the AED (that failed to convert their tachyarrhythmia) contributes to saving young lives in the future. I know that over the past decade AED's have been applied to hundreds of collapsed athletes and sadly the ECG's captured by those devices have not contributed to a greater understanding of cardiac arrest in youth.

Teaching CPR to Adults versus Teens

I write this blog at my own peril. Whenever I promote this concept the push back is always intense, but I remain steadfast. That said I want to be clear right off the top I am not talking about a 90/10 deal but more of a 55/45 arrangement. I simply feel it would be beneficial to re-direct some of the universal enthusiasm for teaching CPR to teenagers toward teaching CPR to Adults. I don't believe teens should not be taught CPR, I just know that more adults should.

Adults hang with adults, teenagers hang with teenagers. I get it, it's not an absolute, but it is a fairly accurate generalization. There are not too many teenagers in a typical workplace. There are not too many teenagers at the gym at 11:00 pm when the senior men's league is playing basketball. There are not too many teenagers living in adult only condos and communities.

In the game of resuscitation the prize is increased survival to discharge for out-of-hospital cardiac arrest (OOHCA) and we need to build a team that can win now and win in the future. To win now we need adults to find a few hours in their busy schedule to learn CPR.

Adults experience the vast majority of cardiac arrest and they must take the majority of the responsibility for responding to cardiac arrest. Although teenagers are capable of performing appropriately during a cardiac emergency we cannot download the responsibility for saving our lives onto them. Think about all of the places where you spend significant blocks of time. Think of all the places where you are engaged in activity that may place you at increased risk for cardiac arrest. How often are there teenagers about?

In Ontario there is a well supported push to teach CPR to every grade nine student.  My thought is that yes we should teach CPR to every grade nine student - right after we teach CPR to every elementary and high school teacher, principal and support staff that work in our schools. If a student or a teacher collapses to the ground, VSA, in cardiac arrest, adults should not be watching helplessly and praying that a thirteen year old student steps up and saves the day. In Ontario cardiac arrest kills more than 9,000 people each year. I'm not sure that deferring improving that statistic until the current cohort of grade nine students comes of age is the best strategy. We need to be looking at much shorter term fixes.

Expecting young teens to perform CPR in a real life situation places an unfair emotional burden on them. I've listened to dozens of real life CPR stories: the storyteller speaks as if it happened yesterday even if it happened 15 years ago, their voice waivers and their eyes may fill with tears. Performing real life CPR is a traumatic experience that most people never forget. It seems a little weak and irresponsible to look to our children to fix the problem of historically dismal survival rates for out-of-hospital cardiac arrest.

Physically people weighing less than 120 lbs find it very challenging to perform effective chest compressions for more than a few seconds. I've evaluated CPR compressions performed by over 300 grade nine students on metered Laerdal manikins and the smaller kids are too fatigued to achieve an effective compression depth after only a few reps. Poor CPR is the equivalent of no CPR.  All of the research on improving survival to discharge rates for cardiac arrest  points to other solutions, none of the research suggests that teenagers are the answer.

The evidence is unequivocal, most cardiac arrest survivors benefit from an effective bystander intervention which includes quality CPR and/or the application of an AED. The communities with the highest survival rates for OOHCA are the communities with the highest rate of bystander intervention. Over the next ten years the communities that will enjoy the greatest improvement in survival rates for cardiac arrest are the communities that teach CPR to the greatest number of ADULTS.

Teaching CPR to thirteen year olds may pay dividends in 2025, in the meantime if you are over age twenty five recognize your civic responsibility and learn CPR this year.

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.