1. How did Early Heart Attack Care get its start?

Early Heart Attack Care got its start with thrombolytic therapy. It introduced the intracoronary events leading to the total occlusion bringing about myocardial damage. Dissolving the clot has lead to reduction in mortality and morbidity. The earlier the clot is dissolved, the more benefits to the patient.

2. How effective has total time reduction been in thrombolytic therapy?

The National Heart Attack Alert program has set as its goal reducing time within the Emergency Department to less than 1/2 hour. However 70-80% of the total time delays relate to outside of the hospital activities. The best data so far has reduced this to 75 minutes. Thus the combination of the two still puts us an 1 1/2 hour into the acute myocardial infarction.

3. How efficient is this overall approach?

Unfortunately not all heart patients receive thrombolytic therapy. Information so far is that 25% of heart attack patients receive thrombolytic therapy and only 10% of these receive within the golden first hour where maximum benefits take place. Left out are patients who don't have ST elevations, patients who have contraindications because of stroke or GI bleeding, and patients who come in too late to treat with thrombolytic therapy. Thus the overall efficiency from this approach is not the best way to practice Early Heart Attack Care.

4. Why is there a need to further shift the paradigm of Early Heart Attack Care to the prodromal stage? Can the barrier to this be overcome?

We need to shift the paradigm of Early Heart Attack Care to the prodromal stage where acute prevention can best take place. With thrombolytic therapy if patients are treat within the first hour, information so far points out that 40% of such patients do not suffer damage thus exposing "acute prevention" of a heart attack when patients are treated immediately. In the prodromal stage, acute prevention is even more possible and has an even broader window of opportunity for this to take place. The problem to date has been overcoming the barrier to this approach.

5. What is the importance of making chest pain and chest discomfort a risk factor for myocardial infarction?

Chest pain (or delaying when you are having chest pain) needs to be identified as a risk factor for an acute myocardial infarction. By doing so it will allow us to get on a learning curve about chest pain and see that it is not chest pain itself that is the problem, but the chest discomfort (milder) which is a prelude to the chest pain. This to date lacks adequate public health awareness for advantage to be taking of this fact.

6. What is "Acute Prevention" of a heart attack? Why is this strategy not being employed? How can this strategy be employed?

Acute prevention of a heart attack can take place thrombolyticly but also can take place much more efficiently at the prodromal stage. This strategy presently does not get adequate attention from the US Public Health Service as an "acute prevention" strategy.

7. What has focused interviews with heart attack patients in Coronary Care Units taught us?

Focused interviews with heart attack patients continues to teach us that heart attacks just do not happen abruptly, but occur in most cases over a period of time with symptoms that are recognizable and identifiable enough for intervention to take place that could amount to acute prevention of the heart attack. Heart attacks have beginnings and this simple message needs a National public awareness campaign on this scale as that seen with hypertension, cigarette smoking and elevated cholesterol.

8. Have these beginnings of heart attacks been recognized in the literature?

Beginnings of heart attacks have been described in the literature for the last 75 years under prodromal angina and represents a form of unstable angina in which soft symptoms herald the onset of the impending myocardial infarction before the chest pain.

9. What is the difference between the two forms of chest pain presentation? Why is this so important in awareness programs in the heart attack problem?

The difference between chest pain and chest discomfort is like night and day in that the public is not totally aware that heart attacks have beginnings that are soft and not hard as seen in prolonged and severe chest pain. Denial and procrastination cannot be given as a reason for delay until the proper cardiac awareness program on these "smoke detector" symptoms of a heart attack are considered adequate.

10. What do Cardiologists in the United States think about prodromal angina? Is there a mandate coming from their findings?

This will be presented in full detail from the recent questionnaire.

11. Can prodromal angina be taught to the public? How has it become a worldwide message? What is the St. Agnes Healthcare EHAC program?

The St. Agnes Healthcare EHAC program is a Early Heart Attack Care educational program aimed at patients with prodromal symptoms of a heart attack. It uses a cliff scene to risk stratify the presentations of a heart attack and attempts to change behavior by getting the viewer to choose the entry level for maximal benefits to take place. Once recognition is accomplished it uses a deputization program to give importance to the activation phase and the need for all of us to combine our efforts "army like" in the war against heart attack. The EHAC message has now spread throughout the USA and is becoming Worldwide. Simply put, it is a specific targeted awareness program on early symptom recognition of a heart attack (the prodromal approach).

12. Has this EHAC education on risk stratification (utilizing the cliff scene) and deputization program changed behavior in the community?

Yes, this educational program has been measured in school children as well as in the community. The GUSTO I (206) patients from St. Agnes Healthcare had reduction in time outside the hospital to 75 minutes.

13. Has this emphasis exposed problems in the timing of onset of myocardial infarction? Does pre-conditioning benefits of prodromal angina exist? How does reperfusion relate to this?

The beginnings of a heart attack are hard to define. They are characterized by opening and closure of the coronary vessel clinically as well as subclinically. This may be the reason for the potential benefits seen in prodromal angina patients. The question comes up, is this related to pre-conditioning or is this related to reperfusion?

14. What is a Community Sarcomere?

Other indices measuring the community hospital performance will be discussed. Once the basic subunit (community sarcomere) is in place it allows the message of heart attack beginnings to be sent to the community. The community sarcomere utilizes the EHAC message in the Community and the low probability work up in the Chest Pain Center similar to the myosin and actin seen with the basic subunit within the heart muscle. Slippage is avoided by meshing the gears effectively and efficiently.

15. What is a strategy to take advantage of early symptom recognition of a heart attack (prodromal angina) and provide a reawakening awareness of it?

Perhaps the most interesting discovery has been the input from audiences being taught Early Heart Attack Care. It relates to personal life rememberancesof when loved ones experienced the beginnings of a heart attack and did not survive because action was not taken soon enough. The sudden realization of this is a reawakening not only what took place but is now possible to prevent.

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