EHAC Position Statement

Infraction of the rules comes about when there are missed signals resulting in failure to detect early signs and symptoms (so called "prodromata"). The penalty when discussing myocardial infarction is severe in that life is lost and cardiac invalidism may result. This does not have to take place. There is no need for this to take place. We set up boundaries in cardiac care because we presume we know the answers. In dealing with the community we use the same logic that we did twenty years ago. Back then we didn't want the patient to know much about his medical history in that it would presumably, adversely affect him. Now, we use the same logic, i.e., we don't want the public to have hysteria about chest pain because it may invoke fear and perhaps excessive testing, driving up the cost of health care. Thus we negate the possible approach of a full and active community participation without giving it a chance. This logic would be okay if all were going well, but when we have the nation's number one disease, killing and maiming each day and early cardiac care with clot dissolving therapy only reaching 20% of the heart attack population we should not tolerate it. We should become upset and set about practicing zero tolerance and give a chance to any new idea that may take advantage of present day early cardiac care. The better logic should be "don't knock it unless you have tried it". We talked about risk stratification after a heart attack, but that is too late. What about risk stratification before a heart attack, especially when the event is starting to occur? Here there is a window of opportunity that occurs before the crash of death or destruction of muscle. If we take advantage of the fact that a significant number of heart attack patients experience prodromal symptoms long before the crash, we find a way to manage the problem provided that we can detect these early symptoms. Early detection is the key to solving this problem. The initial presentation of a heart attack is not easily recognizable or treated properly. The disease goes undetected until the crash takes place. To change this community wide programs need to be set up to simplify and make this detection practical and feasible.

Prevention is the key word in all of medicine. Prevention may come from the direction of wellness such as that seen with the well baby clinic type mentality...But prevention is not truly appreciated until it comes from the other side of the equation, i.e., death and disease. When one deals constantly with the problem of death and destruction one finds out that this need not take place; it does so because of time delays that occur because early warning signs are not properly addressed. We should be upset with this and aim to correct it. The secret in early detection lies in history taking.

History taking does not require a physician to be present but can be taken by the nurse, the paramedic and even the lay person. If the history of early warning signs of a heart attack can be
taught, can it be done effectively without causing mass hysteria? We have to find out about this, but we can't do so by putting our heads into the sand. We need to approach it directly. If we can clue in early on a significant number of heart attack patients and can teach this technique, then all we need to do is hook up the delivery of such patients to centers in hospitals set for early cardiac care, be it clot dissolving or cardioprotection. These centers may be chest pain emergency rooms or early heart attack care centers or just emergency rooms with fast track protocols responding to a true cardiac emergency.

Intelligent patients and intelligent communities can make the difference in future cardiac care. The medical profession can only go so far. What is needed are attempts at solutions of the heart attack problems by focusing on earlier stages that are present long before the crash leading to a heart attack or sudden death. To preach without attempting to implement has been the way of the past. What is needed in the future are approaches that simplify the message and take advantage of early heart attack care by hooking up to it at the appropriate time. To do less is to add more to the problem then to the solution. Zero tolerance for complacency in the present environment needs to be emphasized time and time again.

Raymond D. Bahr, M.D., F.A.C.P.
Medical Director
Paul Dudley White Coronary Care System
St. Agnes Hospital