THE ARTICLE, “Needed for heart attack victims ‘Entitled Instruction,’” by Morton Brotman in the July 10 Evening Sun, deserves equal time and equal space for correction of its inaccuracies. Most importantly, though, constructive points need to be made about the heart attack problem and what the public needs to know. The purpose of this rebuttal is not to belittle Brotman and his opinions, but to straighten out the facts and encourage community participation in delivering early heart attack victims to hospitals where maximum care is now available.

To say that the medical profession “neglects the arming of heart attack patients with tips for survival” is as false a statement as I have heard. Quite the contrary, the medical profession, the Maryland Heart Association and the Center for Health Education continues to emphasize the need for early heart attack care.

The best way to educate the community is through the educational system. This was initiated several years ago when the Maryland Heart Association was able to get a resolution passed by the Maryland State Board of Education, as well as a proclamation by Governor Hughes, stating that cardiopulmonary resuscitation is to be taught at all high school in Maryland.

Included as a part of that educational package is knowledge about the early warning signs of a heart attack and the need to get the victim into the hospital as early as possible. Unfortunately, this does not always occur, because in most cases the victim is not able to separate out what he should do. Psychological defense mechanisms that normally help us often hurt us at this critical point. They keep the victim from seeking early cardiac care. This is the reason why 500,000 people die each year in the United States outside the hospital. It is because of delayed care.

How best to beef up the community and bring early heart attack patients into hospitals at early stages? This is the question that Brotman raised in his article but finished it by beating down on the medical profession for lack of interest in doing so. Well, here lies the most important step needed to attack the overall problem of heart attack. Hospitals, physicians and nurses can only do so much. They can only deal with the patient when he or she arrives. The greatest enemy is time. If the individual cannot seek out help early, how can we overcome this problem?

We do it by promulgating the need for executive-minded spouses or executive-minded people who will be close to the person suffering the heart attack. We define this person as one knowledgeable in early warning signs of a heart attack, who knows that the individual in most cases will delay but one who will immediately call 911 to get the person to the nearest hospital in the shortest period of time. We act on the theory “it is better to be safe than sorry,” especially in an illness that kills so frequently and so fast but yet is completely reversible if actions are taken early.

The Heart Association puts out a pamphlet, “Act To Survive,” for the community in this regard. All too often, however, we are reacting to the damages. What is important is to know when the patient’s chest pain is a signal to potential danger. It is unstable when it is frequent and recurrent and not relieved by rest or nitroglycerin. Then it is crucial that the patient seek out medical attention early.

Medical attention for meaningful chest pain should always be at the hospital and not the physician’s office. It is true that not all chest pain is heart-related, but it is important that cardiac causes be ruled out before attributing it to other causes such as anxiety.

What, then, is meaningful chest pain? First of all, most patients don’t call it pain, they call it pressure. It lies in the center of the chest. It comes on slowly, builds up and then seems to radiate to the neck, jaw or the inner aspect of the left arm. Early, it may come and go and not be perceived as severe and, as a result, people procrastinate.

Later, when it becomes oppressive and vise-like, it is described as a resembling weight or a Mack truck sitting on the chest. Usually it is associated with other symptoms, such as a cold, drenching sweat, marked weakness even to the point of passing out, nausea, vomiting and shortness of breath.

The clue to success here is that when such symptoms occur to someone in your surroundings it is most important to behave like the people in the E. F. Hutton commercial, who stop everything and listen. If we do so and act quickly, we will be contributing greatly to this person’s life. If we all do this, we would markedly reduce the mortality figures with this illness.

My only constructive criticism of the medical literature has to do with too much emphasis on the risk factors of smoking, hypertension and elevated cholesterol level rather than chest pain itself. It is true that chest pain is a clinical manifestation of heart disease, but the delay in seeking medical attention early should be considered a real risk factor. Once meaningful chest pain occurs, the patient’s life is on the line in terms of sudden death or loss of quality of life through muscle destruction.

In summary, then, early cardiac care needs to be linked to early heart attack patients with involvement of the community as a whole to respond to patients experiencing meaningful chest pain. The key here is to focus on the patient with an “E. F. Hutton approach” that will allow us to maximize present-day optimal cardiac care.

Participation of the community in the past has been given lip service or a laissez-faire attitude. The above information, if adopted, should allow the community to be organized in an effective and efficient manner to deliver heart attack patients to the hospital as early as possible, when cardiac care is at its best.

Raymond D. Bahr, M. D., is the director of the Paul Dudley White Coronary Care System at St-Agnes Hospital.

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