Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early heart Attack Care (EHAC)
Raymond D. Bahr, MD, FACP, FACCMedical Director
The Paul Dudley White Coronary Care System
St. Agnes HealthCare
Baltimore, MD
Henry D. McIntosh, MD, FACP, FACC
Medical Director
Prevention and Rehabilitation Center
St. Joseph's Heart Institute
St. Joseph's Hospital
Tampa, FL
Quick Overview
The significance of these observations has not been more emphatically supported than by Simon Dack, MD, in 1941.2 He stated: Reperfusion therapy continues to be a standard of care for eligible patients in the treatment of acute myocardial infarction (AMI), but both thrombolytic therapy and primary angioplasty are limited by human response time to this life-threatening event. The optimal time in which an occluded vessel should be reperfused is not met in many cases either because of patient or hospital delay. It has been estimated that only 25% of patients with AMI receive reperfusion therapy, and of these, less than 10% receive it within the "golden first hour." (11-13)
As long as heart attack care usually begins only after there is evidence to suggest total occlusion of the vessel, success will continue to elude us. The barrier that needs to be overcome is the lack of therapeutic involvement before the occlusion occurs. This is blurred by misconceptions about the importance of prodroma recognition needed for an early response. These so called "soft symptoms," such as chest discomfort, are believed by many to be too difficult to pick out and are diluted by patients with atypical chest pain without evidence of myocardial ischemia. The fear that the emergency department (ED) will be saturated with the "wrong" patients, those with noncardiac-related chest pain, has been given as the excuse in the past for not further educating the public about early recognition of a heart attack.
What appears to be changing this perception, however, is the development in Chest Pain Centers (CPCs) of a critical pathway that embraces an ED evaluation for patients with "low probability of having myocardial ischemia." Evidence to date (14-17) shows that up to 80% of such patients admitted to a CPC and promptly evaluated can be discharged home from the ED at one-half the cost of a 2- to 3-day inpatient rule-out admission. Now hospitals can have cardiac outreach programs calling for patients with milder forms of chest discomfort to be evaluated to determine if the symptoms are or are not manifestation of early ischemic heart disease.
Can the public and, more importantly, clinicians be taught to identify the characteristics of mild symptoms that are likely to be prodromata of a myocardial ischemic event? To explore this possibility, a questionnaire was designed by the authors of this article and mailed in October 1995 to approximately 15,550 American College of Cardiology (ACC) members in the United States (see page 10). Its purpose was to see that if recognizable prodromal symptoms do exist, earlier intervention may be initiated more frequently and injury to the myocardium can be prevented. Thus, more lives could be saved with this approach rather than the strategy of waiting for the vessel to totally occlude and then start the meter of heart attack care.
There were 658 responses from the ACC members as well as 157 responses from the members of the American College of Emergency Physicians (ACEP). Cardiologists were equally divided between interventionalists and noninterventionalists. The questionnaire included 16 questions that had been previously analyzed for clarity and content by Derek Gill, PhD, Professor and Chair, and Lucy Rapaci, Graduate Student, Department of Sociology and Anthropology, University of Maryland Baltimore County Campus.
Responses to this questionnaire indicated that mild chest symptoms are frequently recognized before the onset of the severe, prolonged chest pain that is characteristic of a heart attack. In most cases these symptoms presented frequently in a waxing and waning manner. Eighty-one percent felt that such symptoms were significant enough to be clinically important, 81% felt that the general public was unaware of the potential significance of these mild symptoms, and 84% of those responding felt that in most cases there was a significant window of opportunity to permit intervention to minimize myocardial damage. Respondents felt that the lack of community response to these "soft symptoms" was due to lack of knowledge as well as denial. Respondents further believed that chest pain and chest discomfort should be considered as risk factors for acute MI. Although chest pain hysteria and the overburdening of EDs were of concern, 93% of the respondents agreed that education about prodromal symptoms would result in an increased number of patients with heart attacks being treated earlier. Also, 87% of those responding agreed that EDs should present a user-friendly attitude to encourage earlier presentations of heart attack.
Many of the respondents agreed that this prodromal approach would amount to a larger number of lives saved than that predicted by the National Heart Attack Alert Program (NHAAP). (18) It was further agreed that patients with prodromal symptoms should be directed to the hospital for cardiac evaluation rather than calling their physician's office for an appointment. Patients presenting with a specific symptom complex of prodromal symptoms were diagnosed by 92% of respondents to have a form of unstable angina. Table 1 offers a description of prodromal angina for a public education campaign. Seventy-one percent agreed that the existence of a low-probability workup in the ED would encourage patients with prodromal symptoms to come to the hospital.
Finally, 81% of those responding believed that a National Heart, Lung, and Blood Institute Bethesda Conference should be convened to discuss subjects such as chest pain as a risk factor, prodromal symptoms recognition of a heart attack and myocardial ischemia in the same way as the "golden first hour" is seen in trauma. Thus, there is an urgent need for an increase in awareness and proper interpretation for the "soft symptoms" described in the literature as premonitory or prodromal symptoms.
In a recent editorial in The Lancet, Richard Horton stated, (19) "interpretive medicine is neither the privileging of a single ideal method for conducting clinical research nor the abandoning of reason for the freedom of arbitrary clinical judgment. Rather it reflects a recognition that clinical decisions are made through a plurality of means, each of which requires profound interpretive scrutiny in its own right. This broader view of how we construct and apply medical knowledge allows us to fuse evidence with experience . . ." In the questionnaire report above, community action based on the responses of cardiologists' experiences from focused interviews with heart attack patients is an example of interpretive medicine applied to myocardial ischemia and injury.
THE SHIFTING PARADIGM TO EARLY HEART
ATTACK CARE (EHAC)
QUESTIONNAIRE
Results of the questionnaire are shown in ( ).Respondees included 658 members of the American College of Cardiology and 157 members of the American College of Emergency Physicians.
1. From what percent of your patients do you obtain a history of mild chest symptoms before the severe, prolonged chest pain of a heart attack?
75-100% (13.2%) 50-74% (41.1%) 25-49% (34.4%) 0-24% (9.9%) Missing (1.3%)
2. From what percent of your patients do you obtain a history of "waxing and waning" symptoms (intermittent) before the severe and prolonged chest pain almost universally suspected to represent a heart attack?
75-100% (10.4%) 50-74% (33%) 25-49% (38.7%) 0-24% (16.5%) Missing (1.3%)
3. In your experience, are such prodromal symptoms usually significant enough to be interpreted as potentially clinically important?
YES (81%) NO (7.1%) NOT SURE (10%) Missing (1.8%)
4. In your experience, do you think that the general public is aware enough of the potential significance of such mild symptoms to act on them?
YES (7.5%) NO (81.4%) NOT SURE (9.8%) Missing (1.3%)
5. How important is a consideration of the increasing frequency and/or severity of previously mild or stuttering symptoms in your decision making?
Very Slightly Not
Important Important Important Important Missing
(69.7%) (23%) (4.7%) (1.2%) (1.3%)
6. In your opinion, does the occurrence of such mild, occasionally stuttering symptoms give time for a sufficient window of opportunity to permit intervention in the course of an acute myocardial ischemic event and thereby minimize permanent myocardial injury and/or death?
YES (84.3%) NO (3.3%) NOT SURE (11.3%) Missing (1.1%)
7. Do you think that a patient's lack of appropriate rapid action in response to the previously described mild symptoms is due to:
Denial (33.7%)
or
Lack of knowledge as to the potential seriousness of such symptoms (33.7%)
Both (31.5%) Missing (1.1%)
8. In your opinion, should chest pain be considered a risk factor for an acute myocardial ischemic event?
YES (83.9%) NO (13.4%) Missing (2.7%)
9. In your opinion, should chest discomfort, as described previously, be considered as a risk factor for an acute myocardial ischemic event?
YES (88%) NO (9.9%) Missing (2.1%)
10. In your judgment, would educational efforts designed to foster public acceptance that the occurrence of prodromal symptoms, as described previously, are as great, if not greater, a risk to one's health as an elevated cholesterol, hypertension, and/or cigarette smoking result in:
Chest pain hysteria YES (45.1%) NO (47.5%) Missing (7.4%)
Over burdening
Emergency Departments YES (48%) NO (44.6%) Missing (7.4%)
An increased number of
patients with heart attacks
treated earlier YES (93%) NO (5.3%) Missing (1.7%)
11. In your experience, should all Emergency Departments present a user-friendly attitude to the public to encourage earlier presentation for evaluation of the previously described symptoms?
YES (86.9%) NO (2.9%) NOT SURE (8.7%) Missing (1.5%)
12. The NHLBI's National Heart Attack Alert Program (NHAAP) is predicted to save 15,000 lives each year in the United States from the efforts to encourage earlier initiation of thrombolytic therapy in patients with an acute myocardial infarction by reducing the door-to-treatment time in the Emergency Departments. What is your estimate of the number of lives that might be saved by earlier recognition and cardioprotecting patients experiencing the prodromal symptoms previously discussed?
5 to 15,000 (31.1%) 50,000 to 150,000 (13.2%)
15 to 50,000 (37.7%) > 150,000 (3.8%)
Missing (14.1%)
13. Do you, and those in your office, instruct patients who experience new onset (within 2-3 days) chest discomfort (denied vehemently as pain) with a stuttering presentation that appears to worsen with activity and be relieved with rest to:
a) Call for an office appointment
YES (28.8%) NO (48.2%) Missing (23%)
b) Seek prompt attention (that day) in a medical facility
YES (78.2%) NO (10.3%) Missing (11.5%)
c) Go directly to a hospital Emergency Department for a Cardiology evaluation.
YES (70%) NO (16.5%) Missing (13.5%)
14. In your experience, does the specific symptom complex discussed in question 13 represent unstable angina that should be urgently evaluated?
YES (92.6%) NO (4.5%) Missing (2.8%)
15. Would (or does) the existence in the hospital Emergency Department of a focused critical pathway for the evaluation of patients with a "low probability" of ischemia prompt you to send such patients, as discussed in question 13, immediately to the Emergency Department?
YES (71.6%) NO (22.1%) Missing (6.4%)
16. Would you be in favor of a Bethesda Conference on Early Heart Attack Care that would include topics such as chest pain as a risk factor, the value of prodromal heart attack recognition, and myocardial ischemia, the medical equivalent of trauma?
YES (81.7%) NO (10.4%) Missing (7.8%)
References
1. Kahn MH. Prodromal symptoms in angina pectoris. Am J Med Sci. 1926;clxxii:418.
2. Master AM, Dack S, Jaffe HL. Premonitory symptoms of acute coronary occlusion; a study of 260 cases. Ann Intern Med. 1941;14:1155.
3. Solomon HA, Edwards AL, Killip T. Prodromata in acute myocardial infarction. Circulation. 1969;40:463-471.
4. Harper RW, Kennedy G, DeSanctis RW, et al. The incidence and pattern of angina prior to acute myocardial infarction: a study of 577 cases.
Am Heart J. 1979;97:178-183.
5. Kouvaras G, Bacoulas G. Unstable angina pectoris as a warning symptom before acute myocardial infarction. Q J Med. 1987;64:679-684.
6. Kermani A, Haque AN, Faruqui AMA. Prodromal symptoms in acute myocardial infarction. Pak Heart J. 1992;25:25-28.
7. Bahr RD. Prodromal symptoms of a heart attack. J Am Coll Cardiol. 1992;20:751-752. Letter.
8. Bahr RD. Emphasizing chest pain as a symptom of heart attack. JAMA. 1993;270:2435-2436. Letter.
9. Bahr RD. Access to early heart attack care: chest pain as a risk factor for heart attacks, and the emergence of early cardiac care centers. Md Med J. 1992;41:133-137.
10. Bahr RD. The EHAC strategy: citizens chart the course for healthy people in the year 2000. J Cardiovasc Manag. 1995;6:19-25.
11. Bahr RD, Zeigler RG. Early cardiac care-the final risk factor. Pennsylvania J of Health, Physician Education, Recreation and Dance (HPERD). Fall, 1992:27-28.
12. Cragg DR, Friedman HZ, Bonema JD, et al. Outcomes of patients with acute myocardial infarction who are ineligible for thrombolytic therapy. Ann Intern Med. 1991;115:173-177.
13. Cannon CP, Antman EM, Walls R, et al. Time as an adjunctive agent to thrombolytic therapy. J Thromb Thrombolysis. 1994;1:27-34.
14. Muller DWM, Topol EJ. Selection of patients with acute myocardial infarction for thrombolytic therapy. Ann Intern Med. 1990;113:949-960.
15. Gibler WB, Walsh RA, Levy RC, et al. Rapid diagnostic and treatment centers in the emergency department for patients with chest pain. Circulation. 1992;86:I-15. Abstract.
16. Rodriquez S, Cowfer JP, Lyston DJ, et al. Clinical efficacy and cost effectiveness of rapid emergency department rule out myocardial infarction and noninvasive cardiac evaluation in patients with acute chest pain. J Am Coll Cardiol. 1994;284A. Abstract.
17. Lewis WR, Lee TY, Amsterdam EA. Immediate exercise testing in the assessment of low risk patients presenting to the emergency room with acute chest pain. 65th Annual Scientific Sessions. American Heart Association 1992. Abstract.
18. National Heart Attack Alert Program Coordinating Committee 60 Minutes to Treatment Working Group. Emergency Department: Rapid Identification and Treatment of Patients with Acute Myocardial Infarction. Bethesda, MD: National Heart, Lung, and Blood Institute; September 1993.
US Department of Health and Human Services, NIH publication no. 93-3278.
19. Horton R. The interpretive turn. Lancet. 1995;346:8966. Editorial.
Return to Index of Articles for Clinician;
Volume 14.4
- Faculty Listing 3
- Introduction: Community Message in Acute Myocardial Ischemia 4
- Concept of Community Chest Pain Centers in Emergency Departments 5
- Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early Heart Attack Care (EHAC) 7
- The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference 12
- From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives?Measuring Quality of Care for Patients With Cardiovascular Disease 16
- Improving Lay Responses to Cardiovascular Emergencies and the Potential of Shifting the Paradigm to Early Heart Attack Care 18
- National Survey of Chest Pain Centers Rationale and Potential Results 21
- Outpatient Rule-Out Myocardial Infarction in Observation Units 22
- Reducing Time to Thrombolytic Treatment 24
- Intervention Programs to Reduce Patient Delays in Acute Myocardial Infarction 29
- Public Education Using the Early Heart Attack Care Program Shawnee Mission Medical Center 31
- School Component: Early Heart Attack Care Program Development and Evaluation 33
- Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction 36
- Precipitating Factors in Acute Cardiovascular Disease 41
- Use of Myocardial Perfusion Imaging in the Emergency Department for Risk Stratification 44
- The Evolution of Chest Pain Centers: The Impact of Technological Advances on the Evaluation of Patients With Possible Acute Ischemic Coronary Syndrome 47
- Critical Pathways for Triage and Treatment of Chest Pain Patients in the Emergency Department 53
- Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction 56
- The Key to Success in the Chest Pain Emergency Department: The Observational Role of theNurse 59
- Triage in Moderate Risk Patients With Chest Pain: The Emerging Role of Real-Time Continuous ECG Monitoring 61
- Diffusion of Innovations: The Introduction and Impact of the Chest Pain Emergency
- Department and its Comparison to the Coronary Care Unit Development 64
- Economics of Chest Pain Centers: What Really Matters? 68
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