‘Tis The Coronary Season

 

# 9471

 

If history is any gauge the three deadliest coronary days of the year will occur over the next two weeks; Christmas day, the day after Christmas, and New Year’s Day.   Events that are commonly called `Christmas Coronaries’ or `Hanukkah Heart Attacks’.

 

Fifteen years ago, a study looked at the rate of heart attacks in the United States, and found that Acute Myocardial Infarctions (AMIs) run as much 53% higher during the winter months than than during the summer.

 

Seasonal distribution of acute myocardial infarction in the second National Registry of Myocardial Infarction.

Spencer FA, Goldberg RJ, Becker RC, Gore JM.

 

While cold weather combined with strenuous physical activity (like clearing snow from sidewalks) has often been blamed for this spike, even in balmy Southern California, studies have shown a 33% increase in heart attacks over the holidays (see below).

When Throughout the Year Is Coronary Death Most Likely to Occur?

A 12-Year Population-Based Analysis of More Than 220 000 Cases

Robert A. Kloner, MD, PhD; W. Kenneth Poole, PhD; Rebecca L. Perritt, MS

Non-climate related factors – like over indulgence in food and alcohol, diminished activity levels, forgetting to take prescription medicines, and combined holiday stressors like shopping, running up debt, traveling, meal preparation, and the angst that comes from dysfunctional family gatherings are likely contributors to this yearly spike. 

 

But increasingly influenza and other respiratory infections have been linked to this seasonal increase in heart attacks.

 

In 2012, in Study: Influenza And Heart Attacks, we looked at research that appeared in the Journal of Infectious Diseases that suggested Influenza - and other acute respiratory infections - can act as a trigger for heart attacks. The same issue carried an editorial called Increasing Evidence That Influenza Is a Trigger for Cardiovascular Disease.

 

Influenza Infection and Risk of Acute Myocardial Infarction in England and Wales: A CALIBER Self-Controlled Case Series Study

Charlotte Warren-Gash, Andrew C. Hayward1, Harry Hemingway2, Spiros Denaxas2, Sara L. Thomas3, Adam D. Timmis5, Heather Whitaker6 and Liam Smeeth4

In 2010, in CMAJ: Flu Vaccinations Reduce Heart Attack Risk we saw what would turn out to be a controversial study (see Vaccine/Heart Attack Study Questioned) that strongly suggested that those over the age of 40 who get a seasonal flu vaccine each year may reduce their risk of a heart attack by as much as 19%.

 

Last year (October 2013), in JAMA: Flu Vaccine and Cardiovascular Outcomes, we looked at a meta-analysis of  5 published and 1 unpublished randomized clinical trials involving  6735 patients – that found among those who had previously had a heart attack, the receipt of a flu vaccine was linked to a 55% reduction in having another major cardiac event in the next few months.

 

So the idea that heart attacks may be linked to influenza infection is hardly new.

 

In late October of this year, the Texas Heart Institute published this article, suggesting that tens of thousands of cardiac deaths could be prevented if every high-risk cardiac patient got the flu shot each year.

 

Research Shows Flu Can Trigger Heart Attacks

Influenza vaccinations could prevent thousands of deaths from heart disease

People who are at risk of heart disease should receive the influenza vaccine every autumn. Research shows that influenza epidemics are associated with a rise in deaths from heart disease and that flu can actually trigger the heart attacks that result in death.

However, only about 60 percent of people in the U.S. who ought to have a flu vaccination actually have one, said Mohammad Madjid, MD, MSc, a senior research scientist at the Atherosclerosis Research Lab of the Texas Heart Institute.

(Continue . . . )

 

If their hypothesis is correct – given the expected reduced effectiveness of this year’s flu vaccine (see CDC HAN Advisory On `Drifted’ H3N2 Seasonal Flu Virus) and the rising tide of H3N2 influenza across the country – the next couple of weeks could prove very busy for the nation’s EMS crews and Coronary care units.

But regardless of the effectiveness of this year’s flu shot, and influenza’s effects on cardiovascular events, even on an `average day’ roughly 1,000 people suffer a Sudden Cardiac Arrest (SCA) in the United States.

 

This from the Heart Rhythm Association:

• Sudden Cardiac Arrest (SCA) is a leading cause of death in the United States, claiming more than 350,000 lives each year.
• Approximately 92% of those who experience sudden cardiac arrest do not survive.
• SCA kills more than 1,000 people a day, or one person every 90 seconds

 

What the people who witness these events do in the first few minutes can mean the difference between life and death for the stricken individual. Luckily, hands-only CPR (cardio-pulmonary resuscitation) is easier to do than ever before, and there are thousands of AEDs (automated external defibrillators) stationed in public venues across the nation.

 

With a little bit of training, you have the potential to save someone’s life.

 

While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.  To learn how to use an AED, you can use this online training module  I wrote about in CPR Skills & AED Simulator.  A  CPR class only takes a few hours, can be fun, and is well worth the effort.  

 

To find a local CPR course contact your local chapter of the American Red Cross, the American Heart Association, or (usually) your local fire department or EMS can steer you to a class.

 

Of course, despite your best efforts, many SCA victims will not survive. It isn’t at all like on TV, where 75% of  recipients of CPR survive.  Even when cardiac arrests occur inside a hospital, the survival to discharge rate is less than 40%. Outside the hospital, the odds of seeing a good outcome are lower.

 

While there are no guarantee of success, early and coordinated action taken by bystanders (calling 911, starting CPR, using AED if available) can substantially improve the SCA’s chances of survival. 

 

For more on heart attacks, and CPR, you may wish to visit some of these earlier blogs.

 

Deadlier Than For The Male

Survivability Of Non-Shockable Rhythms With New CPR Guidelines

Fear Of Trying

NPM11: Early CPR Saves Lives

NPM14: CPR Skills & AED Simulator

Source American Heart Association

Note: This is day 14 of National Preparedness Month.  Follow this year’s campaign on Twitter by searching for the #NatlPrep or #NPM14 hash tag. This month, as part of NPM14, I’ll be rerunning some updated  preparedness essays, along with some new ones.

 

#9075

 

Although we often talk about preparedness in terms of having an emergency plan and  the right supplies (First Aid Kit, Emergency Radio, Bottled Water, Full Pantry, etc.), it is also important to have the right skills to deal with an emergency. 

 

Basic stuff – like how to use a fire extinguisher, how to turn off the gas supply to your home or business, how to stop bleeding or apply first aid.

One of the most common emergency situations you are likely to encounter is witnessing a Sudden Cardiac Arrest (SCA).  More than a thousand occur every day across the nation, often in public places like parking lots, shopping malls, and houses of worship.   

 

This from the Heart Rhythm Association:

• Sudden Cardiac Arrest (SCA) is a leading cause of death in the United States, claiming more than 350,000 lives each year. 
• Approximately 92% of those who experience sudden cardiac arrest do not survive.
• SCA kills more than 1,000 people a day, or one person every 90 seconds

What the people who witness these events do in the first few minutes can mean the difference between life and death for the stricken individual. Luckily, hands-only CPR (cardio-pulmonary resuscitation) is easier to do than ever before, and there are thousands of AEDs (automated external defibrillators) stationed in public venues across the nation.

 

With a little bit of training, you have the potential to save someone’s life.

 

AEDs are designed to be used by laypersons who ideally should have received some AED training.  Like doing CPR, the required skills are relatively simple, but they do require some degree of familiarity.  I would strongly encourage everyone to take a CPR class, and if you already done so – take a refresher course every couple of years.

 

While this blog isn’t a substitute for taking a CPR class, it can help familiarize you with the basics.

 

Witnessing a cardiac arrest, particularly of a loved-one, can be a terrifying and traumatic experience. Far too often, bystanders are paralyzed into doing nothing while they wait for rescuers to arrive. As a paramedic, only rarely did I arrive on scene to find someone attempting to resuscitate a patient.

 

Almost inevitably, however, some kind soul had placed a pillow under the head of the victim to make them more `comfortable’, effectively closing off their airway.

 

Consequently, even with the advanced life support equipment we carried, our success rate in reviving these patients was dismally low.

 

Luckily, the new hands only resuscitation method -  which eliminates the need for mouth-to-mouth ventilation - makes doing CPR easier than ever before. But hand’s on training is still important, if you expect to be able to react properly during an emergency. While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.

 

A CPR class only takes a few hours, can be fun, and is well worth the effort.

 

To find a local CPR course contact your local chapter of the American Red Cross, the American Heart Association, or (usually) your local fire department or EMS can steer you to a class.

 

Last  year a buddy of mine passed along a link to an online training site that, in a few short minutes, can familiarize the layperson with what to do when confronted by a sudden cardiac arrest, and what to expect when opening and using an AED.

 

This interactive video is particularly well done, and is provided by the Medtronic Foundation, in conjunction with the Heart Rescue Project.  First the three steps you should know, then the video.

 

What to do if you see someone suddenly collapse.

If you see someone collapse suddenly, check if the victim is responsive. If not, remember these three easy steps.

Call 911

Have them send help. Stay on the line and listen for further instructions.

Start Chest Compressions

If the person is not breathing normally, start chest compressions. Push down hard and fast in the center of the chest. Keep your arms straight. Send someone to find an AED.

Use An AED

The AED (automated external defibrillator) is a portable medical device that delivers an electrical shock to restart a person’s heart. It provides voice prompts that tell you exactly what to do and will only administer a shock if needed, so there’s no reason to hesitate.

It only takes a few minutes to familiarize yourself with the operations of an AED by visiting the following website.  

LINK

 

I should point out that not all cardiac arrests can be corrected by defibrillation, even if conducted in a timely manner. There are non-shockable arrhythmias that an AED cannot convert to sinus rhythm.

Non-shockable cardiac arrest arrhythmias are asystole (flat line) and PEA (Pulseless Electrical Activity) – what we used to call back in the stone age of EMS, electromechanical dissociation.

Neither of which respond to defibrillation.

Patients can sometimes still be saved with CPR alone, at least until the right cardiac meds can be administered. For more on all of this, we have the press release from the American Heart Association.

 

Guidelines-based CPR saves more non-shockable cardiac arrest victims

April 02, 2012

Study Highlights:

• CPR can save someone with cardiac arrest even if they don’t respond to a defibrillator.
• People with non-shockable cardiac arrest are more likely to live if they receive CPR based on recent guidelines emphasizing chest compressions.
• The American Heart Association’s CPR guidelines emphasizing chest compressions are saving more lives, according to a new study.

 

Of course, despite your best efforts, many SCA victims will not survive. It isn’t at all like on TV, where 75% of  recipients of CPR survive.  Even when cardiac arrests occur inside a hospital, the survival to discharge rate is less than 40%. Outside the hospital, the odds of seeing a good outcome are lower.

 

While there are no guarantee of success, early and coordinated action taken by bystanders (calling 911, starting CPR, using AED if available) can substantially improve the SCA’s chances of survival. 

 

For more on heart attacks, and CPR, you may wish to visit some of these earlier blogs.

 

Deadlier Than For The Male

Survivability Of Non-Shockable Rhythms With New CPR Guidelines

Fear Of Trying

NPM11: Early CPR Saves Lives

How Not To Be Swept Away This Summer

A rip current as seen from the beach – Credit NOAA 

 

# 8700

 

Although often life threatening situations are often telegraphed well in advance – such as through hurricane or tornado warnings -  sometimes they appear without warning, even in idyllic settings such as while taking a dip at the beach.

 

While some people fret over the exceedingly low risk of a shark attack, or worry over swimming too soon after a meal, the real danger lies in the hard to spot, but none-the-less deadly rip currents, that can form along the shore.

 

This week (June 1st-June 7th) is National Rip Current Awareness Week (yes, it’s a real thing), and NOAA and other agencies are hoping to inform the public as to the dangers of, and the correct way to escape, rip currents.   

 

Although I am a strong swimmer, and have spent much of my life either living on, or near, the water, I’ve had two occasions where I’ve been overpowered by a rip current.  Once when I was 18 and skin diving in the Florida Keys, and again 40 years later, enjoying a vigorous pounding from the surf off St. Augustine Beach.  

 

Both times, knowing how to swim across – not against – the current saved my life.

 

Each year the United States Life Saving Organization (representing lifeguards and water rescue personnel around the country) estimates that at least a hundred people weren’t as lucky, and that rip currents are responsible for 80% of rescues performed by beach lifeguards

 
NOAA’s Rip Current Safety Page has a lot of good information, including:

 

How to Identify Rip Currents

Look for any of these clues:

• a channel of churning, choppy water
• an area having a notable difference in water color
• a line of foam, seaweed, or debris moving steadily seaward
• a break in the incoming wave pattern

None, one, or more of the above clues may indicate the presence of rip currents. Rip currents are often not readily or easily identifiable to the average beachgoer. For your safety, be aware of this major surf zone hazard. Polarized sunglasses make it easier to see the rip current clues provided above.

Photo courtesy of the U.S. Army Corps of Engineers Field Research Facility at Duck, NC.

How to Avoid and Survive Rip Currents

Learn how to swim!

• Never swim alone.
• Be cautious at all times, especially when swimming at unguarded beaches. If in doubt, don’t go out!
• Whenever possible, swim at a lifeguard protected beach.
• Obey all instructions and orders from lifeguards.
• If caught in a rip current, remain calm to conserve energy and think clearly.
• Don’t fight the current. Swim out of the current in a direction following the shoreline. When out of the current, swim towards shore.
• If you are unable to swim out of the rip current, float or calmly tread water. When out of the current, swim towards shore.
• If you are still unable to reach shore, draw attention to yourself:  face the shore, wave your arms, and yell for help.
• If you see someone in trouble, get help from a lifeguard. If a lifeguard is not available, have someone call 9-1-1 . Throw the rip current victim something that floats and yell instructions on how to escape. Remember, many people drown while trying to save someone else from a rip current.

 

While nothing beats a beautiful day at the beach, there are hazards there that must be accounted for.  To help you this summer to make your visit a safe one, NOAA maintains a Beach Hazards and Safety page:

 

And lastly, in addition to packing the beach towels, sunscreen, and picnic basket . . .  don’t forget the first aid kit.  And if you haven’t taken a CPR course or a refresher in recent years (see A Minute Now Could Save A Life Later), consider packing that bit of expertise along with you as well.

Marital Status & Cardiac Mortality: A Matter Of Wife Or Death?

 

# 8369

 

As a retired paramedic who plied his modest skills throughout the 1970s across three notorious `cardiac cities’ (Phoenix, AZ, St. Petersburg & Bradenton, FL) – and now reaching `that age’ where I have to think about such things on a more personal level -  I have more than a passing interest in heart disease and heart attacks.

 

There’s been a good deal of research to show that married men live longer than their divorced or unmarried counterparts (see Harvard Health Watch Marriage and men's health), but far less is known about the health effects of marriage for women.

 

We’ve an open access study today, published in the journal BMC Medicine, that attempts to answer this question – at least in regards to Ischemic Heart Disease (IHD).  Utilizing the vast stores of data accumulated from the UK's Million Women Study - a comprehensive survey of more than 1.3 million women aged 50 or older recruited between 1996 and 2001- researchers were able to include data from more than 700,000 women in their study.

 

While they found that women who were married (or living with a partner) had the same risk of developing heart disease as single women, they found that women with partners were 28% less likely to die from heart disease.

 

First, a look at the abstract (the entire study is available at the link below), then I’ll be back with a bit more.

 

Marital status and ischemic heart disease incidence and mortality in women: a large prospective study

Sarah Floud^*, Angela Balkwill, Dexter Canoy, F Lucy Wright, Gillian K Reeves, Jane Green, Valerie Beral, Benjamin J Cairns and the Million Women Study Collaborators

Abstract

Background

Being married has been associated with a lower mortality from ischemic heart disease (IHD) in men, but there is less evidence of an association for women, and it is unclear whether the associations with being married are similar for incident and for fatal IHD. We examined the relation between marital status and IHD incidence and mortality in the Million Women Study.

Methods

A total of 734,626 women (mean age 60 years) without previous heart disease, stroke or cancer, were followed prospectively for hospital admissions and deaths. Adjusted relative risks (RRs) for IHD were calculated using Cox regression in women who were married or living with a partner versus women who were not. The role of 14 socio-economic, lifestyle and other potential confounding factors was investigated.

Results

81% of women reported being married or living with a partner and they were less likely to live in deprived areas, to smoke or be physically inactive, but had a higher alcohol intake than women who were not married or living with a partner. During 8.8 years of follow-up, 30,747 women had a first IHD event (hospital admission or death) and 2,148 died from IHD. Women who were married or living with a partner had a similar risk of a first IHD event as women who were not (RR = 0.99, 95% confidence interval (CI) 0.96 to 1.02), but a significantly lower risk of IHD mortality (RR = 0.72, 95% CI 0.66 to 0.80, P <0.0001). This lower risk of IHD death was evident both in women with and without a prior IHD hospital admission (respectively: RR = 0.72, 95% CI 0.60 to 0.85, P <0.0001, n = 683; and 0.70, 95% CI 0.62 to 0.78, P <0.0001, n = 1,465). These findings did not vary appreciably between women of different socio-economic groups or by lifestyle and other factors.

Conclusions

After adjustment for socioeconomic, lifestyle and other factors, women who were married or living with a partner had a similar risk of developing IHD but a substantially lower IHD mortality compared to women who were not married or living with a partner.

 

While this is likely the largest study of this kind, it is not the first to show that married men and women tend to outlive those who live alone.

 

Roughly a year ago, a Finnish study, published in the European Journal of Preventive Cardiology found that both men and women who lived alone are at a higher risk of having a heart attack, and had a worse prognosis when they did. Being married (or partnered) was linked to a "considerably better prognosis of acute cardiac events both before hospitalization and after reaching the hospital alive".

 

Prognosis of acute coronary events is worse in patients living alone: the FINAMI myocardial infarction register

Aino Lammintausta1, Juhani KE Airaksinen1, Pirjo Immonen-Räihä1, Jorma Torppa2, Antero Y Kesäniemi3, Matti Ketonen4, Heli Koukkunen5,6, Päivi Kärjä-Koskenkari3, Seppo Lehto6, Veikko Salomaa2

Abstract

Background Single living has been associated with a worse prognosis of acute coronary syndrome (ACS). We aimed to study the relation of sociodemographic characteristics to the morbidity, mortality, and case fatality (CF) of ACS in a large population-based ACS register.

Methods The population-based FINAMI myocardial infarction register recorded 15,330 cases of ACS among persons aged 35–99 years in Finland in 1993–2002. Record linkage with the files of Statistics Finland provided information on sociodemographic characteristics (marital status, household size).

Results ACS incidence and 28-day mortality rate were higher in unmarried men and women in all age groups. The prehospital CF of incident ACS was higher in single living and/or unmarried 35–64-year-old people. The 28-day CF was 26% (95% confidence interval, CI, 24–29%) in married men, 42% (95% CI 37–47%) in men who had previously been married, and 51% (95% CI 46–57%) in never-married men. Among women, the corresponding figures were 20% (95% CI 15–24%), 32% (95% CI 25–39%), and 43% (95% CI 31–56%). Most of these CF differences were apparent already at the prehospital phase. The only difference in treatment was that middle-aged men living alone or unmarried received thrombolysis less often. The disparities in ACS morbidity and mortality by marital status tended to widen during the study period.

Conclusions Single living and/or being unmarried increases the risk of having a heart attack and worsens its prognosis both in men and women regardless of age. Most of the excess mortality appears already before the hospital admission and seems not to be related to differences in treatment of ACS.

 

Higher pre-hospital mortality from cardiac events among single people is likely explained – at least in part – to not having someone to call for help, or initiate CPR, in a timely fashion. But this study also found that 28-day mortality rates were significantly higher in both unmarried men (60%-168%) and  unmarried women (71%-175%) than their married counterparts.

 

Heart attacks are not – as once believed – predominantly a `male problem’.  Thirty years ago, if a man  experienced `chest pain’, doctors would immediately suspect a heart attack, but if a similarly aged woman presented with the same symptoms, they’d think first `gall bladder’. 

 

Complicating matters, women don’t always show the same classic symptoms (e.g. crushing chest pain radiating down the left arm, dyspnea, diaphoresis) that men usually do when having a heart attack. The American Heart Association’s article Heart Attack Symptoms in Women explains some of the differences.

 

In Deadlier Than For The Male, we looked at research that examined the impact of coronary heart disease on women, and differences in their symptoms and the treatment they receive.  Their conclusion: Contrary to long held beliefs, heart attacks for women can actually be deadlier than for the male.

 

Exactly why partnered people fare better when it comes to cardiac events isn’t really understood, although a number of theories (more emotional & physical support, better diet, better adherence to meds, etc.) have been proposed.  And it should also be noted that these studies focused on cardiac events and mortality.

 

Future studies are needed to look at marriage’s effects on other factors and events, such as strokes and cancer.

 

According to The American Heart Association (data for 2009) every year an estimated 785,000 Americans experience their first heart attack, and another 470,000 suffer a recurrent heart attack. They also estimate another 195,000 `silent’ myocardial infarctions occur each year.

So now would be a good time to remind my readers (partnered, or otherwise) to of the importance of learning CPR. 

Compression-only CPR is now the standard for laypeople, and so you don’t have to worry about doing mouth-to-mouth. While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.

 

A class only takes a few hours, and it could end up helping you save the life of someone you love.

 

To find a local CPR course contact your local chapter of the American Red Cross, the American Heart Association, or (usually) your local fire department or EMS can steer you to a class.

A Minute Now Could Save A Life Later

 

# 7984

 

As a former CPR Instructor (American Heart Association & Red Cross), I’ve had the pleasure of teaching hundreds of people how perform this life saving technique, and as a paramedic, I’ve experienced the genuine pride of arriving on the scene to find one of my students doing effective CPR . . . on his grandfather (who survived).

 

While we carried the requisite EKG/Defibrillator, cardiac meds, and telemetry . . .  unless someone at the scene of a heart attack had initiated CPR before our arrival, the reality was, the odds of seeing a good patient outcome were next to zero.

 

One of the most common emergency situations you are likely to encounter is witnessing a Sudden Cardiac Arrest (SCA).  More than a thousand occur every day across the nation, often in public places like parking lots, shopping malls, and houses of worship

.   

This from the Heart Rhythm Association:

• Sudden Cardiac Arrest (SCA) is a leading cause of death in the United States, claiming more than 350,000 lives each year.^1,2  
• An estimated 382,800 people experience sudden cardiac arrest in the United States each year.
• Approximately 92% of those who experience sudden cardiac arrest do not survive.
• SCA kills more than 1,000 people a day, or one person every 90 seconds ^1,2 — a number great than the number of deaths each year from breast cancer, lung cancer, stroke or AIDS.

 

What the people who witness these events do in the first few minutes can mean the difference between life and death for the stricken individual. Luckily, hands-only CPR (cardio-pulmonary resuscitation) is easier to do than ever before, and there are now thousands of AEDs (automated external defibrillators) stationed in public venues across the nation.

 

And while taking a class is the preferable way to learn CPR, a new study presented at at the American Heart Association's Scientific Sessions 2013 (Nov 16th-20th) shows that even after watching a 1 minute CPR video, the ability for the layperson to react and respond to a cardiac emergency increases substantially.

 

The press release from the American Heart Association provides the details.

 

 

1 minute of CPR video training could save lives

 

RESS Abstract 19453/157 (Omni Dallas Hotel, Dallas Ballroom D-H)

Just one minute of CPR video training for bystanders in a shopping mall could save lives in emergencies, according to research presented at the American Heart Association's Scientific Sessions 2013.

Researchers used a one-minute CPR video to improve responsiveness and teach compression only CPR to people with no CPR experience.

Participants were divided into two groups: 48 adults looked at the video, while 47 sat idle for one minute. In a private area with a mannequin simulating a sudden collapse, both groups were asked to do "what they thought best." Researchers measured responsiveness as time to call 9-1-1 and start chest compression and CPR quality reflected by chest compression depth, rate and hands-off interval time.

Adults who saw the CPR video called 9-1-1 more frequently, initiated chest compression sooner, had an increased chest compression rate and a decreased hands-off interval, researchers said.

"Given the short length of training, these findings suggest that ultra-brief video training may have potential as a universal intervention for public venues to help bystander reaction and improve CPR skills," said Ashish Panchal, M.D., Ph.D. lead researcher of the study.

 

You can view one of these short videos by clicking this link, or the graphic below.

 

For more , follow this link.

 

In addition to doing CPR, knowing how to use one of the thousands of AED’s (automated external defibrillators) stationed in public areas like shopping malls, airports, bus terminals, schools, and other venues can be lifesaving.

 

AEDs are designed to be used by laypersons who ideally should have received some AED training.  Like doing CPR, the required skills are relatively simple, but they do require some degree of familiarity.

Earlier this year, in Interactive Video: Using An AED For Sudden Cardiac Arrest (SCA), I highlighted a brief, but informative, online presentation designed to teach you how to use one of these devices.

NPM13: CPR Skills & AED Simulator

Source American Heart Association

 

Note: This is day 29 of National Preparedness Month.  Follow this year’s campaign on Twitter by searching for the #NPM or #NPM13 hash tag.

This month, as part of NPM13, I’ll be rerunning some updated  preparedness essays, along with some new ones.

 

#7823

 

Although we often talk about preparedness in terms of having an emergency plan and  the right supplies (First Aid Kit, Emergency Radio, Bottled Water, Full Pantry, etc.), it is also important to have the right skills to deal with an emergency.  Basic stuff – like how to use a fire extinguisher, how to turn off the gas supply to your home or business, how to stop bleeding or apply first aid.

 

One of the most common emergency situations you are likely to encounter is witnessing a Sudden Cardiac Arrest (SCA).  More than a thousand occur every day across the nation, often in public places like parking lots, shopping malls, and houses of worship.   

 

This from the Heart Rhythm Association:

 

• Sudden Cardiac Arrest (SCA) is a leading cause of death in the United States, claiming more than 350,000 lives each year.^1,2  
• An estimated 382,800 people experience sudden cardiac arrest in the United States each year.
• Approximately 92% of those who experience sudden cardiac arrest do not survive.
• SCA kills more than 1,000 people a day, or one person every 90 seconds ^1,2 — a number great than the number of deaths each year from breast cancer, lung cancer, stroke or AIDS.

What the people who witness these events do in the first few minutes can mean the difference between life and death for the stricken individual. Luckily, hands-only CPR (cardio-pulmonary resuscitation) is easier to do than ever before, and there are thousands of AEDs (automated external defibrillators) stationed in public venues across the nation.

 

With a little bit of training, you can literally save someone’s life.

 

AEDs are designed to be used by laypersons who ideally should have received some AED training.  Like doing CPR, the required skills are relatively simple, but they do require some degree of familiarity.  I would strongly encourage everyone to take a CPR class, and if you already done so – take a refresher course every couple of years.

 

While this blog isn’t a substitute for taking a CPR class, it can help familiarize you with the basics.

 

Witnessing a cardiac arrest, particularly of a loved-one, can be a terrifying and traumatic experience. Far too often, bystanders are paralyzed into doing nothing while they wait for rescuers to arrive. As a paramedic, only rarely did I arrive on scene to find someone attempting to resuscitate a patient.

 

Almost inevitably, however, some kind soul had placed a pillow under the head of the victim to make them more `comfortable’, effectively closing off their airway.

 

Consequently, even with the advanced life support equipment we carried, our success rate in reviving these patients was dismally low.

 

Luckily, the new hands only resuscitation method -  which eliminates the need for mouth-to-mouth ventilation - makes doing CPR easier than ever before. But hand’s on training is still important, if you expect to be able to react properly during an emergency. While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.

 

A CPR class only takes a few hours, can be fun, and is well worth the effort.

 

To find a local CPR course contact your local chapter of the American Red Cross, the American Heart Association, or (usually) your local fire department or EMS can steer you to a class.

 

Earlier this year a buddy of mine (thanks, Cliff) passed along a link to an online training site that, in a few short minutes, can familiarize the layperson with what to do when confronted by a sudden cardiac arrest, and what to expect when opening and using an AED.

 

This interactive video is particularly well done, and is provided by the Medtronic Foundation, in conjunction with the Heart Rescue Project.  First the three steps you should know, then the video.

What to do if you see someone suddenly collapse.

If you see someone collapse suddenly, check if the victim is responsive. If not, remember these three easy steps.

Call 911

Have them send help. Stay on the line and listen for further instructions.

Start Chest Compressions

If the person is not breathing normally, start chest compressions. Push down hard and fast in the center of the chest. Keep your arms straight. Send someone to find an AED.

Use An AED

The AED (automated external defibrillator) is a portable medical device that delivers an electrical shock to restart a person’s heart. It provides voice prompts that tell you exactly what to do and will only administer a shock if needed, so there’s no reason to hesitate.

 

It only takes a few minutes to familiarize yourself with the operations of an AED by visiting the following website.  

LINK

I should point out that not all cardiac arrests can be corrected by defibrillation, even if conducted in a timely manner. There are non-shockable arrhythmias that an AED cannot convert to sinus rhythm.

 

Non-shockable cardiac arrest arrhythmias are asystole (flat line) and PEA (Pulseless Electrical Activity) – what we used to call back in the stone age of EMS, electromechanical dissociation.

 

Neither of which respond to defibrillation.

 

Patients can sometimes still be saved with CPR alone, at least until the right cardiac meds can be administered. For more on all of this, we have the press release from the American Heart Association.

 

Guidelines-based CPR saves more non-shockable cardiac arrest victims

April 02, 2012

Study Highlights:

• CPR can save someone with cardiac arrest even if they don’t respond to a defibrillator.
• People with non-shockable cardiac arrest are more likely to live if they receive CPR based on recent guidelines emphasizing chest compressions.
• The American Heart Association’s CPR guidelines emphasizing chest compressions are saving more lives, according to a new study.

 

Of course, despite your best efforts, many SCA victims will not survive. But early and coordinated action taken by bystanders (calling 911, starting CPR, using AED if available) can substantially improve their chances.

 

For more on heart attacks, and CPR, you may wish to visit some of these earlier blogs.

 

Deadlier Than For The Male

Survivability Of Non-Shockable Rhythms With New CPR Guidelines

Fear Of Trying

NPM11: Early CPR Saves Lives

Survivability & Neurological Outcomes With Extended CPR

V-Fib Lead II – Credit Glenlarson Wikipedia Commons

 

 

# 6874

 

Some new studies out today indicate that longer CPR on patients who suffer an in-hospital cardiac arrest can result in improved survival rates.

 

In-hospital cardiac arrests are more likely to survive than out-of-hospital arrests simply because they are generally `witnessed arrests’ so CPR is initiated quicker, and the requisite `crash cart’ and medical personnel trained to use them are readily available.

 

Still, survival rates for in-hospital cardiac arrests are sobering, with a recent study (Trends in Survival after In-Hospital Cardiac Arrest) published in the NEJM  finding that risk-adjusted rates of survival to discharge increased from 13.7% in 2000 to 22.3% in 2009.

 

This improvement also came with a reduction in neurological impairment in the survivors as well.

 

Another study, on a smaller cohort of pediatric (<18 years) patients experiencing in-hospital cardiac arrest found a tripling of survival rates between 2000 and 2009 (see Survival Trends in Pediatric In-Hospital Cardiac Arrests: An Analysis From Get With The Guidelines-Resuscitation Girotra S, Spertus JA, Li Y, et al.), again without higher rates of neurological disability among survivors.

 

One of the trends cited in both of these studies has been a dramatic increase in cardiac arrests due to non-shockable arrhythmias such as asystole (flat line) and PEA (Pulseless Electrical Activity) – what we used to call back in the stone age of EMS, electromechanical dissociation.

 

Neither of which respond to simple defibrillation.

 

Despite this trend, survivability of in-hospital cardiac arrests is improving (see Survivability Of Non-Shockable Rhythms With New CPR Guidelines).

 

Today, we look at a couple of studies that indicate that longer duration CPR for in-hospital arrests can result in better outcomes than previously believed. In the past, the belief has been that after 20 to 25 minutes, most resuscitation attempts become futile.

 

First a press release from Children's Hospital of Philadelphia (CHOP) describing these studies, then the links to the research.

 

 

Longer CPR extends survival in both children and adults

CHOP experts are co-authors of 2 large studies of outcomes after in-hospital cardiac arrest

Experts from The Children's Hospital of Philadelphia were among the leaders of two large national studies showing that extending CPR longer than previously thought useful saves lives in both children and adults. The research teams analyzed impact of duration of cardiopulmonary resuscitation in patients who suffered cardiac arrest while hospitalized.

 

"These findings about the duration of CPR are game-changing, and we hope these results will rapidly affect hospital practice," said Robert A. Berg, M.D., chief of Critical Care Medicine at The Children's Hospital of Philadelphia. Berg is the chair of the Scientific Advisory Board of the American Heart Association's Get With Guidelines-Resuscitation program (GWTG-R). That quality improvement program is the only national registry that tracks and analyzes resuscitation of patients after in-hospital cardiac arrests.

 

The investigators reported data from the GWTG-Resuscitation registry of CPR outcomes in thousands of North American hospital patients in two landmark studies—one in children, published today, the other in adults, published in October 2012.

 

Berg was a co-author of the pediatric study, appearing online today in Circulation, which analyzed hospital records of 3,419 children in the U.S. and Canada from 2000 through 2009. This study, whose first author was Renee I. Matos, M.D., M.P.H., a mentored young investigator, found that among children who suffered in-hospital cardiac arrest, more children than expected survived after prolonged CPR—defined as CPR lasting longer than 35 minutes. Of those children who survived prolonged CPR, over 60 percent had good neurologic outcomes.

 

The conventional thinking has been that CPR is futile after 20 minutes, but Berg said these results challenge that assumption.

 

In addition to Berg, two other co-authors are critical care and resuscitation science specialists at The Children's Hospital of Philadelphia: Vinay M. Nadkarni, M.D., and Peter A. Meaney, M.D., M.P.H.

 

Nadkarni noted that illness categories affected outcomes, with children hospitalized for cardiac surgery having better survival and neurological outcomes than children in all other patient groups.

 

The overall pediatric results paralleled those found in the adult study of 64,000 patients with in-hospital cardiac arrests between 2000 and 2008. Berg also was a co-author of that GWTG-R study, published in The Lancet on Oct. 27, and led by Brahmajee K. Nallamothu, M.P.H., M.D., of the University of Michigan. Patients at hospitals in the top quartile of median CPR duration (25 minutes), had a 12 percent higher chance of surviving cardiac arrest, compared to patients at hospitals in the bottom quartile of median CPR duration (16 minutes). Survivors of prolonged CPR had similar neurological outcomes to those who survived after shorter CPR efforts.

 

The American Heart Association and American Stroke Association designated the adult study as the top finding of the year in heart disease and stroke research in its annual list of major advances. Next steps for CPR researchers are to identify important risk and predictive factors that determine which patients may benefit most from prolonged CPR, and when CPR efforts have become futile. "Taken together, the adult and pediatric results present a clear and hopeful message: persisting longer with CPR can offer better results than previously believed possible," concluded Berg.

(Continue . . . )

 

The link to earlier Lancet report published online: 05 September 2012

 

Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study

Zachary D Goldberger MD, Paul S Chan MD, Prof Robert A Berg MD, Steven L Kronick MD, Colin R Cooke MD , Mingrui Lu MPH , Mousumi Banerjee PhD , Prof Rodney A Hayward MD, Prof Harlan M Krumholz MD , Dr Brahmajee K Nallamothu MD

 

And appearing today in Circulation.

 

Duration of Cardiopulmonary Resuscitation and Illness Category Impact Survival and Neurologic Outcomes for In-hospital Pediatric Cardiac Arrests

Renee I. Matos; R. Scott Watson; Vinay M. Nadkarni; Hsin-Hui Huang; Robert A. Berg; Peter A. Meaney; Christopher L. Carroll; Richard J. Berens; Amy Praestgaard; Lisa Weissfeld; Philip C. Spinella

 

 

Although these studies looked at in-hospital cardiac arrest, the use of AEDs (see Interactive Video: Using An AED For Sudden Cardiac Arrest (SCA)) in public venues, and the teaching of CPR Skills to the lay public, has had a substantial impact on the survivability of out-of-hospital cardiac arrests as well.

 

Luckily, today CPR is easier to do than ever.

 

Compression-only CPR is now the standard for laypeople, and so you don’t have to worry about doing mouth-to-mouth.

While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.

 

A CPR class only takes a few hours, and it could end up helping you save the life of someone you love.

 

Of course, despite your best efforts, many SCA (sudden cardiac arrest) victims will not survive. But early and coordinated action taken by bystanders (calling 911, starting CPR, using AED if available) can substantially improve their chances.

 

For more on heart attacks, and CPR, you may wish to visit some of these earlier blogs.

 

Deadlier Than For The Male

Fear Of Trying

NPM11: Early CPR Saves Lives

Interactive Video: Using An AED For Sudden Cardiac Arrest (SCA)

V-Fib Lead II – Credit Glenlarson Wikipedia Commons

 

 

# 6823

 

Thirty-ahem years ago, I was lucky enough to have one of the first truly portable EKG/Defibrillators in my EMS rig. It was a Life-Pak 5, a museum piece now, but state of the art in 1976. 

 

While having it did increase our ability to revive ardiac arrest patients, the sad truth was that it could take 10 minutes for us to arrive on scene.

 

Often too long to be of much use to the patient unless effective CPR was started before our arrival.

 

Today, there are thousands of AED’s (automated external defibrillators) stationed in public areas like shopping malls, airports, bus terminals, schools, and other venues. Their early use during a cardiac arrest could easily make the difference between a patient’s survival or death.

 

AEDs are designed to be used by laypersons who ideally should have received some AED training.  Like doing CPR, the required skills are relatively simple, but they do require some degree of familiarity.

 

A buddy of mine (thanks, Cliff) passed along a link to an online training site that, in a few short minutes, can familiarize the layperson with what to do when confronted by a sudden cardiac arrest, and what to expect when opening and using an AED.

 

This interactive video is particularly well done, and is provided by the Medtronic Foundation, in conjunction with the Heart Rescue Project.  First the three steps you should know, then the video.

 

What to do if you see someone suddenly collapse.

If you see someone collapse suddenly, check if the victim is responsive. If not, remember these three easy steps.

Call 911

Have them send help. Stay on the line and listen for further instructions.

Start Chest Compressions

If the person is not breathing normally, start chest compressions. Push down hard and fast in the center of the chest. Keep your arms straight. Send someone to find an AED.

Use An AED

The AED (automated external defibrillator) is a portable medical device that delivers an electrical shock to restart a person’s heart. It provides voice prompts that tell you exactly what to do and will only administer a shock if needed, so there’s no reason to hesitate.

 

It only takes a few minutes to familiarize yourself with the operations of an AED by visiting the following website.   And if you haven’t taken a CPR class recently, make it a priority to get recertified.

 

LINK

 

I should point out that not all cardiac arrests can be corrected by defibrillation, even if conducted in a timely manner. There are non-shockable arrhythmias that an AED cannot convert to sinus rhythm.

 

Non-shockable cardiac arrest arrhythmias are asystole (flat line) and PEA (Pulseless Electrical Activity) – what we used to call back in the stone age of EMS, electromechanical dissociation.

 

Neither of which respond to defibrillation.

 

Patients can sometimes still be saved with CPR alone, at least until the right cardiac meds can be administered. For more on all of this, we have the press release from the American Heart Association.

 

Guidelines-based CPR saves more non-shockable cardiac arrest victims

April 02, 2012

Study Highlights:

• CPR can save someone with cardiac arrest even if they don’t respond to a defibrillator.
• People with non-shockable cardiac arrest are more likely to live if they receive CPR based on recent guidelines emphasizing chest compressions.
• The American Heart Association’s CPR guidelines emphasizing chest compressions are saving more lives, according to a new study.

 

 

Of course, despite your best efforts, many SCA victims will not survive. But early and coordinated action taken by bystanders (calling 911, starting CPR, using AED if available) can substantially improve their chances.

 

For more on heart attacks, and CPR, you may wish to visit some of these earlier blogs.

 

Deadlier Than For The Male

Survivability Of Non-Shockable Rhythms With New CPR Guidelines

Fear Of Trying

NPM11: Early CPR Saves Lives

Deadlier Than For The Male

Photo Credit – American Heart Association

 

 

# 6650

 

Although this blog deals primarily with emerging infectious diseases, this week is the 40th anniversary (Oct 1972) of my first job in EMS, and that ties nicely to an oral abstract presented at the 2012 Acute Cardiac Care Congress, which is being held this weekend in Istanbul, Turkey.

 

The subject is the impact of coronary heart disease on women, and differences in their symptoms and the treatment they receive. Their conclusion: Contrary to long held beliefs, heart attacks for women are deadlier than for the male.

At least in the cohort they studied. The abstract can be found at the link below: 

 

 

Are there gender differences in the management of ST-elevation myocardial infarction? Data from ORBI, a prospective registry of 5000 patients.

Guillaume LEURENT (Rennes, FR)

 

 

Note:  STEMIs are serious heart attacks that affect a large portion of cardiac muscle and show up on EKGs (ST segment elevation) and produce a spike in cardiac enzymes (indicative of muscle damage).

STEMI on EKG- credit Wikidoc.org

 

 

Fleshing out this abstract is a press release on the European Society of Cardiology’s website, from which I’ve excerpted portions below (bolding & Italics mine):

 

Women more likely to die from myocardial infarction than men

Gender gap in mortality is independent of patient characteristics, revascularisation delays and revascularisation modalities

 

Topics: Acute Coronary Syndromes (ACS)

Date: 20 Oct 2012

Doctors need to be more careful in the management of STEMI in women to further reduce ischemic time. This means adopting more aggressive reperfusion strategies and treating women the same as men. These actions by patients and doctors will reduce the current gender gap in mortality

Istanbul, Turkey – 20 October 2012: Women are more likely to die from a myocardial infarction than men, according to research presented at the Acute Cardiac Care Congress 2012.

 

The gender gap in mortality was independent of patient characteristics, revascularisation delays and revascularisation modalities. Women also had longer treatment delays, less aggressive treatment, more complications and longer hospital stays. The study was presented by Dr Guillaume Leurent from the Centre Hospitalier Universitaire in Rennes, France.

 

<SNIP>

 

“Previous studies on ST elevation myocardial infarction (STEMI) have shown that women have a worse prognosis, possibly due to longer management delays and less aggressive reperfusion strategies,” said Dr Leurent. “Therefore we used data from ORBI, a prospective registry of 5,000 STEMI patients, to find out whether there were any gender differences in the management of STEMI.”

 

<SNIP>

 

The researchers found significant differences in the management and outcome of STEMI patients according to gender.

 

Women had longer median delays between symptom onset and call for medical assistance (60 vs 44 minutes, p<0.0001) and between admission and reperfusion (45 vs 40 minutes, p=0.011).

 

“Delays of management are significantly longer in women, hence they have a longer ischemic time during which the heart’s blood supply is reduced,” said Dr Leurent. “And reperfusion strategies to restore blood flow are significantly less aggressive – with less fibrinolysis, and fewer coronary angiographies performed.”

 

Intra-hospital mortality was higher in women (9.0% vs 4.0%, p<0.0001). The researchers used 3 adjustment models to determine whether the higher intra-hospital mortality among women was solely due to gender or whether it was due to other factors such as patient characteristics (age, hypertension, smoking, etc) or management.

Dr Leurent said:

<SNIP>

 

Women had more STEMI complications including atrial fibrillation (7% vs 3%, p<0.0001) and longer hospital stays (7.6+4 vs 6.7+4 days, p<0.0001).

 

Women received significantly less of the recommended treatments at discharge. Specifically, they received less antiplatelet agents, beta blockers, ACE inhibitors and statins. They also received less cardiovascular rehabilitation (27% of women vs 47% of men, p<0.0001).

(Continue . . .)

 

 

At the risk of stating the obvious, this study was based on 5000 STEMI patients followed into 9 coronary care units in the Brittany region of France since 2006. Time to treat, aggressiveness in treatment, and outcomes may (or may not) be typical of those seen in other places around the globe.

 

The belief that heart attacks were predominately a `male problem’ was widespread four decades ago. Back then, if a man (over 40) had chest pain, your first thought would be `heart attack’. If a woman of the same age had chest pain, your first thought was more apt to be `gall bladder”.

 

Since then we’ve learned that women certainly have their share of heart attacks, but they don’t always show the same classic symptoms (e.g. crushing chest pain radiating down the left arm, dyspnea, diaphoresis) that men usually do.

 

Which probably explains number of middle-aged women we saw who died abruptly at home without ever calling for help. They apparently chalked up whatever warning signs they had to indigestion, or some other minor ailment.

 

The American Heart Association’s article Heart Attack Symptoms in Women explains the differences.

 

“Although men and women can experience chest pressure that feels like an elephant sitting across the chest, women can experience a heart attack without chest pressure, ” said Nieca Goldberg, M.D., medical director for the Joan H. Tisch Center for Women's Health at NYU’s Langone Medical Center and an American Heart Association volunteer. “Instead they may experience shortness of breath, pressure or pain in the lower chest or upper abdomen, dizziness, lightheadedness or fainting, upper back pressure or extreme fatigue.”

 

Even when the signs are subtle, the consequences can be deadly, especially if the victim doesn’t get help right away.

 

<SNIP>

 

Heart Attack Signs in Women

1. Uncomfortable pressure, squeezing, fullness or pain in the center of your chest. It lasts more than a few minutes, or goes away and comes back.
2. Pain or discomfort in one or both arms, the back, neck, jaw or stomach.
3. Shortness of breath with or without chest discomfort.
4. Other signs such as breaking out in a cold sweat, nausea or lightheadedness.
5. As with men, women’s most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain.

If you have any of these signs, don’t wait more than five minutes before calling for help. Call 9-1-1 and get to a hospital right away.

 

The following 3 minute film from Go Red for Women (starring Emmy-nominated actress Elizabeth Banks) illustrates the point nicely.

 

 

 

And finally, whether the victim is male or female - in the event of full cardiac arrest - having someone at hand with the skills to apply CPR can be lifesaving.

 

Luckily, today CPR is easier to do than ever.

 

Compression-only CPR is now the standard for laypeople, and so you don’t have to worry about doing mouth-to-mouth.

 

While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.

 

A CPR class only takes a few hours, and it could end up helping you save the life of someone you love.

 

For more on the recent changes to bystander CPR, you may wish to visit these recent blogs.

 

CPR As A Requirement For High School Graduation

AHA Unveils 2010 CPR Guidelines

JAMA: Compression Only CPR

MMWR: Sudden Cardiac Arrest Awareness Month