5. Patient education

Heart attacks often are fatal because patients come to the emergency department too late - presenting the clinician with the final stages of a progressive ischemic syndrome. To reduce patient delays in seeking treatment, the community must become aware that heart attacks need not kill, and even may be avoided, if addressed in their initial presentation [35]. Thus, the third contribution of chest pain centers is the prevention of myocardial infarctions through community education.

A questionnaire was recently sent to community-based cardiologists and reported a consensus (80%) opinion that the public is not aware of the importance of early chest symptoms [13]. Thus, community education programs should emphasize the benefits of recognizing the early warning signs of a heart attack - the heart attack can be more easily treated, and possibly prevented, if patients seek early treatment and not wait until the symptoms become debilitating.

Although prodromal symptoms have been described in the literature for the last 75 years, effective early intervention to reduce the progression to an acute myocardial infarction is recent. Approximately 50% of patients with heart attacks report that they had prodromal anginal symptoms before the acute event [36]. In the GUSTO II study, 44% of the 4000 patients with myocardial infarction reported intermittent symptoms over a 2-week period prior to their heart attack [37]. The mortality difference in the GUSTO II trial between patients with myocardial infarction and prodromal unstable angina was 5.2 versus 3.28%. Thus, more patients may be saved with intervention at the prodromal unstable angina stage, as opposed to waiting for the infarction to occur. Further, the most cost-effective way to 'treat' a myocardial infarction may be to avoid it.

Prodromal symptoms, however, present as mild chest discomfort and can be deceiving, in that they are brief and often intermittent (stuttering) in their presentation [16]. Since most people equate a myocardial infarction with severe chest pain, the mild intermittent prodromal symptoms are often ignored, delaying time-critical treatment. To benefit from early intervention, adults should be taught to recognize these subtle prodromal symptoms and the importance of seeking help when they occur in themselves, family or friends.

By concentrating on early heart attack care, the speed and accuracy of diagnosis has improved, and the 'door to needle' time has been substantially reduced - often to under 30 min. The next major improvement in care will come from moving treatment further 'upstream' - reducing the delay from the onset of symptoms to presentation at chest pain centers. The benefits will be two-fold: earlier treatment of patients with myocardial infarction can reduce the severity of the infarction and limit tissue necrosis, while earlier aggressive treatment can now reduce the development of subsequent infarcts. This is also true for patients presenting with unstable angina and NQMI. Although clinical trial designs and measured outcomes differ significantly, Table 1 suggests that adding a GP Ilb/IIIa inhibitor to current therapy is likely to save another 15 lives/infarctions per thousand patients treated.

Chest pain centers are strategically designed to be user-friendly facilities for patients experiencing an early manifestation of ischemic heart disease [35]. Chest pain, or central chest discomfort, should be treated as a predictive tool for an impending acute event [38]. Designating chest pain as a risk factor may help to overcome resistance to early intervention. Making the chest pain centers receptive to all chest pain patients, regardless of cardiac origin, will increase the likelihood that patients will visit chest pain centers 'just to be safe.' Concerns that this approach would result in 'chest pain hysteria', flood emergency departments with ROMI patients, and increase medical costs have proven unfounded. By offering a comprehensive approach, chest pain centers provide prompt and efficient detection and treatment for myocardial infarction and ischemia.

Home | What's New | What is EHAC? | Abstracts & Articles
Reader's Digest | Contact Us | Search

Tips for Searching

www.ehac.org. Site by AllSoldOut Internet Solutions
Visit the Clinical Information EHAC site at www.chestpaincenters.org.
Copyright © 1996-2001 by St. Agnes Healthcare. All Rights Reserved.