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.

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

Survivability Of Non-Shockable Rhythms With New CPR Guidelines

 

 

# 6262

 

 

We’ve a new study this week, appearing in the American Heart Association’s journal Circulation that looks at the survivability of OHCA  (Out of Hospital Cardiac Arrests) with non-shockable rhythms utilizing the new CPR guidelines that stress chest compressions.

 

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.

 

Thirty-five years ago, most cardiac arrests started out with either pulseless ventricular tachycardia or (worse) ventricular fibrillation (both shockable rhythms) - that if not corrected - rapidly progressed to PEA or Asystole and ultimately death.

 

Which is why EMS put such emphasis on getting paramedics equipped with defibrillators and cardiac meds onto ambulances starting in the early 1970s.

 

But in recent years – for reasons that are not altogether understood – the number of shockable cardiac arrests is on the decline, while incidence of PEA and asystole are rising (see JEMS article  “Where Has V Fib Gone: Why today’s EMS crews see less ventricular fibrillation in the field.”)

 

Some researchers propose that better detection and earlier treatment of coronary artery disease may be responsible for this pendulum swing.

  

But with these gains come questions over whether the new standards for CPR – first unveiled in 2005 - work as well for non-shockable cardiac arrests.

 

Which brings us to the study, published earlier this week in the journal Circulation. You’ll find excerpts from the abstract below, but follow the link to read it (or the entire study) in its entirety.

 

Impact of Changes in Resuscitation Practice on Survival and Neurological Outcome after Out-of-Hospital Cardiac Arrest Resulting From Non-Shockable Arrhythmias

Peter J. Kudenchuk1; Jeffrey D. Redshaw; Benjamin A. Stubbs; Carol E. Fahrenbruch; Florence Dumas; Randi Phelps; Jennifer Blackwood; Thomas D. Rea; Mickey S. Eisenberg

 

Background—Out-of-hospital cardiac arrest (OHCA) claims millions of lives worldwide each year. OHCA survival from shockable arrhythmias (ventricular fibrillation/tachycardia) improved in several communities after implementing American Heart Association resuscitation guidelines that eliminated "stacked" shocks and emphasized chest compressions. "Non-shockable" rhythms are now the predominant presentation of OHCA, upon which the benefit of such treatments is uncertain.

<SNIP>

Conclusions—Outcomes from OHCA due to non-shockable rhythms, though poor by comparison with shockable rhythm presentations, improved significantly after implementing resuscitation guideline changes, suggesting their potential to benefit all presentations of OHCA.

 

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.

 

DALLAS, April 2, 2012 — People who have a cardiac arrest that can’t be helped by a defibrillator shock are more likely to survive if given CPR based on updated guidelines that emphasize chest compressions, according to research reported in the American Heart Association journal, Circulation.

 

“By any measure — such as the return of pulse and circulation or improved brain recovery — we found that implementing the new guidelines in these patients resulted in better outcomes from cardiac arrest,” said Peter J. Kudenchuk, M.D., lead author of the study and professor of medicine at the University of Washington in Seattle, Wash.

 

The American Heart Association changed its CPR guidelines in 2005 to recommend more chest compressions with fewer interruptions. The emphasis on chest compressions continued in the 2010 guidelines update.

(Continue . . . )

 

 

All of which illustrates the importance of learning how to do effective CPR.

 

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

MMWR: Out-of-Hospital Cardiac Arrest Surveillance

 

 

# 5728

 

Over the years I’ve written often about the importance of learning CPR, and on occasion, of my own experiences as a paramedic and as an American Red Cross and American Heart Association CPR instructor.

 

The first four or five minutes of any cardiac arrest are the most critical. And resuscitation efforts that are started after that time period are less likely to produce a good outcome.

 

Quite simply, since EMS response times are often longer than 5 minutes - when someone suffers cardiac arrest outside of the hospital – the patient’s ultimate survival hinges greatly on whether bystander CPR is started before help arrives.

 

Last week the CDC’s  MMWR released a surveillance summary that illustrates this point with data gleaned over the past 5 years from 911 Call Centers, EMS services, and Hospitals on OHCA’s (Out Of Hospital Cardiac Arrests).

 

Out-of-Hospital Cardiac Arrest Surveillance --- Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005--December 31, 2010

Surveillance Summaries

July 29, 2011 / 60(SS08);1-19

Bryan McNally, MD, Rachel Robb, MMSc,Monica Mehta, MPH,Kimberly Vellano, MPH,Amy L. Valderrama, PhD, Paula W. Yoon, ScD, Comilla Sasson, MD, Allison Crouch, MPH, Amanda Bray Perez, BS, Robert Merritt, MA, Arthur Kellermann, MD

Abstract

Problem/Condition: Each year, approximately 300,000 persons in the United States experience an out-of-hospital cardiac arrest (OHCA); approximately 92% of persons who experience an OHCA event die. An OHCA is defined as cessation of cardiac mechanical activity that occurs outside of the hospital setting and is confirmed by the absence of signs of circulation. Whereas an OHCA can occur from noncardiac causes (i.e., trauma, drowning, overdose, asphyxia, electrocution, primary respiratory arrests, and other noncardiac etiologies), the majority (70%--85%) of such events have a cardiac cause.

 

The majority of persons who experience an OHCA event, irrespective of etiology, do not receive bystander-assisted cardiopulmonary resuscitation (CPR) or other timely interventions that are known to improve the likelihood of survival to hospital discharge (e.g., defibrillation). Because nearly half of cardiac arrest events are witnessed, efforts to increase survival rates should focus on timely and effective delivery of interventions by bystanders and emergency medical services (EMS) personnel. This is the first report to provide summary data from an OHCA surveillance registry in the United States.

(Continue . . . .)

 

The entire report is detail rich and worth reading, but briefly:

 

In 2004 the CDC, in collaboration with the Emergency Department at the Emory University School of Medicine, began a pilot program called the Cardiac Arrest Registry to Enhance Survival (CARES).

 

This registry – which has since expanded to include 46 EMS agencies in 36 communities in 20 states – evaluates patients who received resuscitative efforts, including CPR or defibrillation, outside of the hospital following a coronary related cardiac arrest.

 

In evaluating 31,689 OCHA events, the registry found that the mean patient age was 64, 61.1% were male, and nearly half (47.3%) were witnessed by a bystander or EMS personnel.  Two thirds occurred at a home or residence, 13.5% in a nursing home or assisted living facility, and roughly 20% in public locations.

 

Just over 20% were pronounced dead at the scene by EMS personnel, while 26.3% survived to be admitted to the hospital.

 

Overall, the survival rate to hospital discharge was 9.6%.

 

Although 36.7% of these cardiac arrests were witnessed by bystanders, less than half (43.8%) of those received bystander CPR, and only 3.7% of those were treated with an AED prior to the arrival of EMS.

 

Among those who received bystander CPR or AED treatment, the survival rate to hospital discharge was 11.2% as opposed to just 7% for those who received no CPR.  

 

A 60% improvement in the survival rate.

 

 

In conclusion, the authors write:

 

The data provided in this report indicate the need for prompt and effective resuscitation efforts. Provision of optimal care at the scene is essential to survival. If a pulse is not restored before EMS transport, additional efforts at the receiving hospital almost invariably fail (23).

 

Education of public officials and community members about the importance of increasing rates of bystander CPR far beyond the current 33.3% and promoting use of early defibrillation by lay and professional rescuers are critical to improving survival of OHCA events. CARES data can be used at the community level to target interventions (e.g., bystander CPR training and AED placement) and assess their effectiveness. CDC uses CARES data for cardiovascular surveillance efforts and makes data available to the public at http://apps.nccd.cdc.gov/NCVDSS_DTM. As statewide CARES registries become available, the data will be used for state-specific OHCA surveillance efforts.

 

With expansion to state-level surveillance, CARES will enable local and state public health departments and EMS agencies to better coordinate their efforts. Such coordination can improve the quality of EMS care and thus increase the proportion of persons who survive an OHCA event.

 

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.

 

This from the American Heart Association.

• Sudden cardiac arrest is a leading cause of death in the U.S.
• Everyone should know how to perform CPR in an emergency.
• Immediate, effective CPR could more than double a victim's chance of survival.
• Push on the chest at a rate of at least 100 beats per minute.
• Push to the beat of "Stayin' Alive" and you could save a life.
• Click here for more information on Hands-Only CPR.

 

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.

 

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.

 

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

Study: Predictors Of Sudden Coronary Death

 

 

# 5714

 

 

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.

Making for just under 1.5 million coronary attacks a year (cite Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics—2010 Update. Circulation. 2010;121:e1-e170).

 

While many people survive their first heart attack, for far too many Americans, their first heart attack is also their last. 

 

Every year American EMS units respond to roughly 300,000 cardiac arrests, and the vast majority of those prove fatal (cite  AHA CPR Stats). Why some people survive their first heart attack, and others do not, has been a subject of considerable interest for many years. 

 

The BMJ journal HEART recently published an article that looks at ECG and clinical predictors of sudden cardiac death. 

 

Electrocardiographic and clinical predictors separating atherosclerotic sudden cardiac death from incident coronary heart disease

Elsayed Z Soliman, Ronald J Prineas, L Douglas Case, Gregory Russell, Wayne Rosamond, Thomas Rea, Nona Sotoodehnia, Wendy S Post, David Siscovick, Bruce M Psaty, Gregory L Burke

 

 

While this study found many commonalities between those who suffer sudden cardiac death and those who survive their heart attacks, researchers found several risk factors that appear to suggest a higher risk of sudden death.

 

• Black race/ethnicity (compared to non-black)
• Hypertension and increased heart rates
• Extreme high or low body mass index

Additionally, ECG readings showing a prolongation of QT interval (QTc) and abnormally inverted T waves were seen as possibly being predictors of a higher risk of sudden cardiac death.

 

This research was conducted at the Epidemiological Cardiology Research Center (EPICARE) at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.

 

The authors conclude by stating that these results need to be validated in another cohort.

 

A press release, with more details, is available on the Wake Forest Medical Center Website.

 

 

Predictors of Dying Suddenly Versus Surviving Heart Attack Identified

WINSTON-SALEM, N.C. – July 25, 2011 – Is it possible to predict whether someone is likely to survive or die suddenly from a heart attack?

 

A new study by researchers at Wake Forest Baptist Medical Center has answered just that.

 

“For some people, the first heart attack is more likely to be their last,” said Elsayed Z. Soliman, M.D., M.Sc., M.S., director of the Epidemiological Cardiology Research Center (EPICARE) at Wake Forest Baptist and lead author of the study. “For these people especially, it is important that we find ways to prevent that first heart attack from ever happening because their chances of living through it are not as good.”

(Continue . . . )

 

 

While preventing that first heart attack is a laudable goal, this is an excellent time to remind my readers of the importance of learning CPR. 

 

This from the American Heart Association.

 

• Sudden cardiac arrest is a leading cause of death in the U.S.
• Everyone should know how to perform CPR in an emergency.
• Immediate, effective CPR could more than double a victim's chance of survival.
• Push on the chest at a rate of at least 100 beats per minute.
• Push to the beat of "Stayin' Alive" and you could save a life.
• Click here for more information on Hands-Only CPR.

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 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.

 

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

Home Is Where The (fatal) Heart Attack Is

 

 

# 5262

 

Yep, that’s me - circa 1976 with my (now museum piece) LifePak 5 (and an almost full head of hair).

 

While I try not to tell paramedic `war stories’, or go out of my way to make this blog about me, every once in awhile I can’t resist throwing in a personal anecdote.

 

In August of 1974 I was among the first 36 D.O.T. paramedic graduates in the state of Florida. With portable defibrillators, IVs, Cardiac meds, and radio telemetry on board - everyone expected us to start saving lives left and right.

 

And while our `saves’ went up, they didn’t go up as dramatically as many hoped.

 

Sure, we had some great saves - particularly among younger patients, drowning victims, and trauma.   

 

But overall, our cardiac arrest success rate was dismal.   Perhaps now, after all these years, we may have a better clue why.

 

First, a quickie lesson in heart attacks and EKGs (the readout of the electrical activity of the heart). 

 

In a cardiac arrest, the patient is pulseless, usually non-breathing, and unable to circulate oxygenated blood to the brain and other organs. Death follows generally in 4 to 10 minutes.

 

But not all pulseless arrests are created equal.

This is bad.

(Ventricular Tachycardia)

 

This is very bad

(Ventricular Fibrillation)

 

And this is worst of all.

(Asystole)

 

 

The first two rhythms strips are considered `shockable’ arrhythmias. The heart may not be beating, but there is still some (albeit, chaotic) electrical activity going on. 

 

Applying an electrical shock promptly enough can often restore NSR (normal sinus rhythm) to a stopped heart. 

 

But despite what you may have seen in the movies, and on television, you can shock an asystolic (flatlined) heart all day long without much hope of success.   

 

There are some cardiac meds that can (rarely) convert asystole to fibrillation, but defibrillation alone is generally futile.

 

 

Yesterday the NIH announced  a study comparing the type of cardiac arrests experienced by people at home verses people who collapsed in public.

 

And the results are fascinating.   At least to an old EMT-II like myself.

 

First, some excerpts from the press release, then a link to the NEJM study, after which I’ll be back with a little more.

 

 

Shockable cardiac arrests are more common in public than home

Comprehensive NIH study helps explain discrepancy in survival rates between cardiac arrests in public and at home

Cardiac arrests that can be treated by electric stimulation, also known as shockable arrests, were found at a higher frequency in public settings than in the home, according to a National Institutes of Health-funded study appearing in the Jan. 27 issue of the New England Journal of Medicine.

 

The study compared home and public cardiac arrests under various scenarios. For example, the study considered whether bystanders or emergency medical services (EMS) personnel witnessed the cardiac arrest, and whether the person experiencing the arrest received treatment with an automatic external defibrillator (AED).

 

In every scenario, a higher percentage of public cardiac arrests were classified as ventricular tachycardia (VT) or ventricular fibrillation (VF), the types of abnormal heart rhythms that can be treated by electric shock.

 

More than one-third of the people who had a cardiac arrest in public and were treated with an AED survived. This is a significant improvement over the roughly 8 percent national average of cardiac arrest survival. In comparison, the overall survival for home-occurring cardiac arrests treated with an AED was 12 percent.

(Continue . . .)

 

Ventricular Tachyarrhythmias after Cardiac Arrest in Public versus at Home

 

Myron L. Weisfeldt, M.D., Siobhan Everson-Stewart, Ph.D., Colleen Sitlani, M.S., Thomas Rea, M.D., Tom P. Aufderheide, M.D., Dianne L. Atkins, M.D., Blair Bigham, M.Sc., Steven C. Brooks, M.D., M.H.Sc., Christopher Foerster, M.Sc., Randal Gray, M.A.Ed., Joseph P. Ornato, M.D., Judy Powell, B.S.N., Peter J. Kudenchuk, M.D., and Laurie J. Morrison, M.D. for the Resuscitation Outcomes Consortium (ROC) Investigators

N Engl J Med 2011; 364:313-321January 27, 2011

(Read Full Report . . . )

 

 

Like all studies, there are limitations to this one.

 

Some assumptions regarding the arrhythmias of successfully cardioverted arrest victims using AEDs (which only shock when they detect VT or VF) had to be made in lieu of actual EKG strips.

 

Likewise, home heart attacks (where AEDs are less likely to be found, or the patient’s collapse witnessed) may have started with VT or VF and progressed to asystole by the time rescuers with their EKGs arrived.

 

But even when you take these items into account, it appears that cardiac arrests that occur in public are far more likely to be a `shockable’ (VT or VF) rhythm than those that occur in the home.

 

This likely has more to do with the age, and physical condition of the patient, than the actual location.  Those who are able to be out and about are probably in somewhat better overall health than those who are house bound.

 

All of which points out the benefits of putting more AEDs in public places, and promoting lay person CPR and AED training. 

 

The authors of this NEJM report conclude:

 

Conclusions

Regardless of whether out-of-hospital cardiac arrests are witnessed by EMS personnel or bystanders and whether AEDs are applied by bystanders, the proportion of arrests with initial ventricular fibrillation or pulseless ventricular tachycardia is much greater in public settings than at home. The incremental value of resuscitation strategies, such as the ready availability of an AED, may be related to the place where the arrest occurs. (Funded by the National Heart, Lung, and Blood Institute and others.)

 

 

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