Pre-hospital ECGs critical for heart attack patients

Lifesaving procedures to open blocked heart arteries could begin much sooner for heart attack patients if electrocardiograms (ECGs) were recorded before they arrive at the hospital and used to put treatment teams into action, according to a scientific statement in Circulation: Journal of the American Heart Association.

Each year, about 920,000 people in the U.S. have a new or recurrent heart attack, also called myocardial infarction (MI). ST-segment elevation myocardial infarction (STEMI) is a common and especially severe type of heart attack. While there are no exact statistics for STEMI, the number has been estimated between 200,000 and 400,000.

Rapid treatment to reopen the blocked artery is vital because more heart muscle dies the longer it’s deprived of blood flow.

Current criteria for evaluating quality of care includes elapsed “door-to-balloon” or “door-to-drug” time — the time span from the moment a patient enters a hospital emergency room until blocked arteries are re-opened either by angioplasty or a clot-busting drug.

However, “the clock starts ticking from the moment a person develops symptoms of a heart attack,” said Henry H. Ting, M.D., lead author of the statement and a cardiologist at the Mayo Clinic in Rochester, Minn. “The pertinent measure of system performance is from the time of first medical contact with paramedics or other emergency medical personnel to reperfusion therapy (reestablishing blood flow to the heart muscle).”

Ting and colleagues evaluated progress since STEMI guidelines were first issued by the American Heart Association and the American College of Cardiology in 2004. They were updated last year. The guidelines recommend that all emergency medical services acquire and use pre-hospital electrocardiograms to evaluate patients with suspected acute coronary syndromes.

“If pre-hospital ECGs were more widely used and integrated with systems of care, the time from first medical contact to balloon reperfusion could be reduced to less than 60 minutes,” Ting said. The recommended goal is 90 minutes or less.

Delays from the time a person has heart attack symptoms to when they receive artery-opening treatment can be divided into four time intervals: (1) symptom onset-to-EMS arrival; (2) EMS arrival-to-hospital arrival; (3) hospital arrival-to-ECG; and (4) ECG-to-reperfusion. Pre-hospital ECG programs, if effectively implemented and coordinated with comprehensive systems of care, have the potential to decrease the latter three time intervals – and eliminate the third one.

The statement presents examples of using pre-hospital ECGs, including systems of care with door-to-balloon times approaching 30 minutes or less. In these systems, pre-hospital ECGs are used to activate the cardiac catheterization laboratory while the patient is en route to the hospital, and the patient is transported directly to the cath lab (bypassing the emergency room evaluation).

Despite the recent recommendations, fewer than 10 percent of EMS systems have adopted the use of pre-hospital ECGs, and the rate has not substantially changed since the mid-1990s.

“Furthermore, even when a pre-hospital ECG is acquired, the information is often not translated into effective action to decrease delays in treatment,” Ting said. “It is a lost opportunity to improve the quality of care for STEMI patients if the information from a prehospital ECG is not used to change downstream processes of care.”

The reluctance of patients with acute coronary syndromes to call 9-1-1 is a major obstacle to realizing the full public health benefits of pre-hospital ECGs and organizing systems of care. Studies show that more than half of STEMI patients take themselves to the hospital rather than use EMS. In addition, recent studies have shown that the longest delay for STEMI patients – two hours on average – is from the time of symptom onset to hospital arrival, said Ting.

Other barriers include:

• ensuring EMS and emergency rooms have the capacity to meet demand for services;
• developing standards for education and quality assurance for EMS providers;
• improving collaboration among EMS, emergency medicine physicians and cardiologists;
• co-ordinating hospital networks to provide the ideal patient care;
• overcoming insurance reimbursement issues for prehospital care;
• studying unintended consequences from implementing pre-hospital ECG programs.

Widespread implementation of pre-hospital ECGs is being addressed by the American Heart Association’s Mission: Lifeline, a national initiative launched in 2007 to improve regional systems of care for patients with STEMI. Mission: Lifeline’s initial phase includes emergency medical services system assessment and improvement.

Co-authors are Harlan M. Krumholz, M.D.; Elizabeth H. Bradley, Ph.D.; David C. Cone, M.D.; Jeptha P. Curtis, M.D.; Barbara J. Drew, R.N., Ph.D.; John M. Field, M.D.; William J. French, M.D.; W. Brian Gibler, M.D.; David C. Goff, M.D., Ph.D.; Alice K. Jacobs, M.D.; Brahmajee K. Nallamothu, M.D.; Robert E. O’Connor, M.D.; and Jeremiah D. Schuur, M.D. Author disclosures are available on the manuscript.

CPR / AED Awareness Week

Out-of-Hospital Cardiac Arrest

Each year, about 310,000 coronary heart disease deaths occur out-of-hospital or in emergency departments in the United States. Of those deaths, about 166,200 are due to sudden cardiac arrest – nearly 450 per day.

• Sudden cardiac arrest can happen to anyone at any time. Many victims appear healthy with no known heart disease or other risk factors.
• Sudden cardiac arrest is not the same as a heart attack. Sudden cardiac arrest occurs when electrical impulses in the heart become rapid or chaotic, which causes the heart to suddenly stop beating. A heart attack occurs when the blood supply to part of the heart muscle is blocked. A heart attack may cause cardiac arrest.

Cardiopulmonary Resuscitation (CPR)

• Less than one-third of out-of-hospital sudden cardiac arrest victims receive bystander CPR.
• Effective bystander CPR, provided immediately after sudden cardiac arrest, can double or triple a victim’s chance of survival.
• The American Heart Association trains more than 10 million people in CPR annually, including health professionals and members of the general public.
• The most effective rate for chest compressions is 100 compressions per minute – the same rhythm as the beat of the BeeGee’s song, “Stayin’ Alive.”

Automated External Defibrillators (AEDs)

• Unless CPR and defibrillation are provided within minutes of collapse, few attempts at resuscitation are successful.
• Even if CPR is performed, defibrillation with an AED is required to stop the abnormal rhythm and restore a normal heart rhythm.
• New technology has made AEDs simple and user-friendly. Clear audio and visual cues tell users what to do when using an AED and coach people through CPR. A shock is delivered only if the victim needs it.
• AEDs are now widely available in public places such as schools, airports and workplaces.

CPR/AED Awareness Survey

• Eighty-nine percent of respondents said they were willing and able to do something to help if they witnessed a medical emergency.
• Few Americans (12%-20%) are confident that they would know when it is appropriate to perform CPR or use an AED.
• At most, roughly four in ten are extremely or very likely to perform CPR on an adult (39%) or child (37%) they know personally.
• Less than 17 percent of Americans believe they are at risk for sudden cardiac arrest.
• The survey was conducted online within the United States by Harris Interactive on behalf of the American Heart Association between January 8, 2008 and January 21, 2008 among 1,132 U.S. residents aged 18 and older.

Public Policy for CPR/AEDs

The American Heart Association supports state public policy initiatives that:

• Promote the access and use of AEDs and establish quality AED programs in high-risk locations
• Encourage bystander CPR and CPR training for professionals who may need to respond to medical emergencies
• Promote increased quality and appropriate use of 9-1-1 systems
• Extend Good Samaritan legal liability protection to all users of AEDs

The American Heart Association also supports increased funding for the Rural and Community Access to Emergency Devices Program, which gives communities funding to place automated external defibrillators (AEDs) in rural areas and trains lay rescuers and first responders to use AEDs.

SCHILLER acquires Medilog

On 1st May, Medilog became part of the SCHILLER group. Medilog will be SCHILLER’s high-end Holter system. Medilog’s additional products are an ideal complement to SCHILLER’s present product range. The SCHILLER group very much looks forward to the coming co-operation.

SCHILLER is a leading international manufacturer and supplier of electrocardiographs, Holter ECG and blood pressure recorders, spirometers, medical IT-solutions, patient monitors and external defibrillators. More than 700 employees work for the SCHILLER group in 28 subsidiaries around the world. The company was founded by Alfred E. Schiller in 1974. The CEO is convinced that the addition of Medilog’s high-end Holter will enhance SCHILLER’s product range. Alfred E. Schiller’s comment on the acquisition: “We, at SCHILLER look forward to the coming co-operation. We are proud to have gained a brand as good as Medilog.”

What does the acquisition mean?

The SCHILLER group, with its leading position on the world market, will make every effort to further boost Medilog’s success. It is already certain, that the Medilog brand name will remain. Medilog will become SCHILLER’s high-end Holter system. Other details of the integration process are not yet fixed.

Medilog

Medilog is the trademark of Huntleigh Healthcare cardiology products, the former Medical Division of Oxford Instruments. Oxford Instruments is a leading international manufacturer of scientific research systems. The Huntleigh group was founded in 1975.

SCHILLER AG

SCHILLER is a leading international manufacturer and supplier of electrocardiographs, long-term ECG and blood pressure recorders, spirometers, medical IT-solutions, patient monitors and external defibrillators. The company was founded by Alfred E. Schiller in 1974. More than 700 employees work for the SCHILLER group in 28 subsidiaries around the world. SCHILLER has subsidiaries providing exclusive service centres in 15 countries and representatives in more than 100 countries worldwide. All shares are owned by the company CEO Alfred E. Schiller. SCHILLER is, and has been fully self-financed for more than 34 years.