Awareness of the EHAC message is awareness of these mild symptom. Perhaps even more important is the awareness that one's behavior must change to take advantage of this early recognition. Paying more attention......, being alert......, and being prepared are analogous to discovering and responding to the smoke before the fire. This knowledge can potentially save more lives than all the new drugs, procedures and surgery now used to treat heart attacks.

Awareness of the symptoms basically consists of the following understandings that need to take place.

1. Central chest discomfort

Patient: "It's not pain, Doc!"

Perception: Chest discomfort has to be severe and knock you "dead in your tracks" before you seek attention. OK?

This response is WRONG

2. The chest discomfort comes and goes, often disappearing for a period of time before it returns and becomes severe.

Patient: "It won't come back.....I hope!"

Perception: It went away before, it'll go away again. OK?

This response is WRONG.

3. Patient not recognized as being in distress.

Patient: "I won't tell anyone. I will just be less active and not recognized."

Perception: My being sick will escape detection. OK?

This response is WRONG

4. Chest discomfort is not emergency enough to call "911"

Patient: "Chest discomfort is not an emergency. I don't have to call "911".

I'd be so embarrassed. I'm not that sick. The neighbors will see me being taken out on a stretcher. Oh my God!"* OK?

This response is WRONG.

*If the patient does not wish to go to the hospital by ambulance, it may be possible to have someone who knows CPR take him quickly in a private car.

DISCUSSION

CORRECT RESPONSE

"If this is the beginning of a heart attack, I can get more preventive care early. Great! I'll check it out! I'll take an aspirin and go to the Emergency Room."

Reader's Digest Article:

The Reader's Digest Condensed Message on Preventing Heart Attack When It Counts (Early)

In heart attack situations

Know that......

The chest pressure may come before the chest pain

Thus it is important to........

Recognize this chest pressure as the "smoke before the fire"

Then become

Proactive rather than reactive

This is the way you will save meaningful lives

Help deliver the message of EHAC

In a nutshell EHAC is central chest discomfort not perceived as chest pain that comes and goes and gets worse with activity and is relieved by rest. It is chest discomfort (not pain, Doc!) that is described as a chest tightness, chest burning, chest ache, chest pressure, or shortness of breath (angina equivalent). It may either radiate to the jaw or to the teeth, to the upper chest, or down the arm or to the back. The patient may break out in a cold sweat, become nauseated, become weak, and perhaps even pass out. The message of EHAC is get the patient with this mild chest discomfort checked out early. Intervention at this stage is secondary prevention at its earliest form.

Two Minute Warning Drill For Having a Heart Attack In seeing patients in cardiology follow-up on a 6 month basis, I usually give the patient a chance to bring me up to date on symptoms and then proceed to do the physical examination interpreting for the patient what I perceive to be the direction for the next several months. Most importantly I let the patient the patient know that should any changes in symptoms take place I need to know early, and that if I don't hear from them, I assume that they are okay. I then finish by giving what I call the "two minute warning drill" aimed directly at intervening at the early stages of a heart attack. I have been asked many times, "what do I tell patients in the last two minutes of their visit that makes them understand clearly what needs to be carried out". The following is given: I let patients know that heart attacks kill.... and that they kill frequently... and that they need not kill. I let them know that in a large percentage of patients (50%) with heart attacks there are beginning signs that are recognizable and detectable (prodromal symptoms). I let them know that these prodromal symptoms usually do not get much attention because of four characteristics: 1. Such chest discomfort is not perceived as chest pain and thus not felt emergency enough to go to the emergency department. Such symptoms are usually milder forms of chest discomfort described as chest pressure, chest ache, burning sensation, or a fullness within the chest. 2. Chest symptoms are usually intermittent which allows the patient to be deceived into thinking that they may not come back or if present will go away. This stuttering effect allows the patient to minimize the diagnosis rather than face the reality that it may be a heart attack. 3. As one can expect, such symptoms are not usually recognizable in a crowd such as the patient with a cardiac arrest or a crushing chest pain. First responders take advantage of this and enable the non-response to take place. 4. Finally, patients with mild symptoms are very reluctant to call 911 with the disturbances that ambulances with loud sirens bring to one's neighborhood. With the above caveats in mind it becomes very important for my patient to understand that when central chest discomfort is occurring it is imperative to pay it major attention and have an early check up for the possibility of this representing the early stages of a heart attack. Heart attacks are vulnerable if they can be intercepted at an earlier stage. This type of intervention prevents not only death to the individual, but prevents loss of heart muscle which is very much important in the pleasures of life (EHAC Message). All of this can be given to the patient within two minutes as a "pep talk" and is analogous to a "half-time pep talk" that the patient needs before being sent out of the office. This message is given to you at this time so that you also can benefit from this two minute EHAC drill. It is very important to realize the fact that primary risk factor reduction can reduce the incidence of coronary disease but it is equally as important to know that when rupture of an atherosclerotic plack has taken place and thrombus formation is forming that it is very important to act early since this could easily become the final risk factor in once's life. Thus chest pain or chest discomfort needs to be emphasized as a major risk factor in acute myocardial infarction. It is important to have an alert system and a plan of action to take advantage of this EHAC knowledge. Raymond D. Bahr, MD, FACP, FACC Medical Director The Paul Dudley White Coronary Care System St. Agnes HealthCare

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