HEART ATTACK CARE LEARNED AT THE BEDSIDE

Courtesy of Sir William Osler

The Johns Hopkins Hospital

Bedside Clues in the CCU Provide a Strategy to Prevent Heart Attacks

What Medical Students and Medical Residents Need to Know

J. Allen Reilly, Chief Resident, St. Agnes HealthCare,

William Gibbs, Medical Student, Ross University

Raymond D. Bahr, MD, Medical Director, The Paul Dudley White Coronary Care System

St. Agnes HealthCare.

The number one health problem in the United States is heart disease. Heart attack deaths contribute the major part of this problem. Heart disease has been in the first place since the turn of the century, but need not continue to occupy that lofty position. Heart disease is vulnerable. Heart attacks do not have to kill, The answer to the heart attack problem lies in clues that can be easily picked up at the patient's bedside. In many ways, the physician is like a detective looking for clues to solve the mystery.

Sir William Osler taught long ago the "medicine is learned at the bedside, not in the classrooms". It is the patient who is the ultimate source of information pertaining to an illness. It is in the history that we find the clues that lead us to the proper diagnosis. Physical examination and laboratory data contribute very little. Dr. Paul Dudley White was often quoted as saying that ninety-five percent of the diagnosis was made once the history had been completed. If this be the case, then what is the missing clue in solving the heart attack problem?

To approach this problem it is important to view the present day management of the heart attack problem. Heart attacks continue to kill Americans to the tune of 600,000 deaths each year. Optimal heart attack care consists of detecting the heart attack early, then reperfusing the obstructed coronary vessel through either thrombolytic therapy or primary balloon opening. Most current research trials focus on this area. Unfortunately, only 25% of heart attack patients receive thrombolytic therapy, and of these, only 10% receive it within the first hours where the best outcome is seen (1.2% mortality versus the usual 6% - 10% mortality). Efforts to improve upon this have to date provided very little improvement.

How does history taking improve our chances to do better? In a recent editorial in the New England Journal of Medicine, Eugene Braunwald, MD discussed patients with prodromal myocardial infarction. He stated that "prodromal symptoms occur in half the patients with heart attacks". These symptoms are usually various forms of chest discomfort, not described as pain, and are mild enough to escape detection. Often these symptoms are intermittent and occur for a short period of time. Often the patient has the feeling that they may not come back. In many cases such symptoms occur over the course of days to weeks. This brings us back to bedside medicine and Sir William Osler's dictum of listening to the patient. Studies carried out at St. Agnes HealthCare confirm the fact that more than 50% of patients have prodromal symptoms. Medical residents have been taught to look for the presence of prolonged, severe, "elephant" or "Mack truck sitting on the chest".......for tombstone ST elevation.......for a friction rub, or a new systolic murmur.......or, worse yet, for patients in cardiac arrest, acute pulmonary edema or cardiogenic shock. The mild symptoms that hint at the occluded coronary vessel are often ignored or forgotten. In the GUSTO II study, patients with prodromal myocardial infarction had a mortality of 6.2%, whereas patients with detected prodromal unstable angina had a mortality of 3.2%. Thus, mortality can be significantly reduced when the prodromal symptoms of a heart attack are detected. Medical residents need to be as interested in early clues as late ones. How can this detection help solve the heart attack problem by reducing heart attack deaths? Simply by appreciating the fact that the beginnings of a heart attack can be detected long before acute myocardial infarction takes place. This allows us to plan our strategy to intervene during the prodromal stage and prevent myocardial infarction from occurring. This Early Heart Attack Care message (EHAC) and can now be taken to the public. Educational programs can be aimed specifically at prodromal symptom recognition. Some critics say that this may cause chest pain hysteria, bring in many false alarms and increase overall health costs. This may have been true in the past, but no longer, because community hospitals across the United States have opened Chest Pain Centers that have a comprehensive, systematic management evaluation for patients presenting with chest pain/chest discomfort. Chest Pain Centers have perfected a pathway in the observation area that identifies patients with low probability of myocardial ischemia and allows 80% of such patient to be discharged home, eliminating inappropriate admissions. Thus, hospitals with Chest Pain Centers now have the machinery to sort out patients with low probability of ischemic heart disease and they open the door to educational programs which encourage patients with milder forms of chest discomfort to be checked out early for heart disease.

In summary, the bedside message that heart attacks have beginnings long enough to be detected and acted upon has the potential to significantly reduce heart attack deaths through early intervention. To accomplish this, medical residents need to appreciate the words of Sir William Osler and look for clues at the bedside about heart attacks to be recognized in their infancy. Acute prevention needs to be brought to the surface and appreciated. As stated above, heart attacks are vulnerable and need not kill. With early detection they can be prevented. Such intervention motivates such individuals to practice healthy lifestyles and reduce other risk factors as well.

Visit The Paul Dudley White Coronary Care System websites:

http:/www.ehac.org

http:/www.chestpain.org

http:/www.chestpaincenters.org

http:/www.cped.org